Starting oral morphine and then switching to maintenance dose in palliative care

Strong Opioids - for moderate to severe pain

First line: Morphine remains the drug of choice

Opiates are used in step 2 and step 3 on the "pain ladder".

• step 2: weak opioids (for moderate pain) e.g. codeine, dihydrocodeine, tramadol
  • these opioids have low potency but can be a useful second step for patients with moderate pain. There is some overlap in 'analgesic effect' between the higher doses of weak opioids and lower doses of strong opioids
  • it is seldom useful to change from one preparation to another (unless to alter side effects). If regular doses do not provide adequate analgesia, move up the ladder to step 3
  • compound preparations of paracetamol and weak opioids may be useful. Only preparations with higher doses of opioids (codeine 30mg, dihydrocodeine 20-30mg) should be used, as the lower strength preparations produce opioid side effects with little analgesia
    
    
• step 3: strong opioids (for moderate to severe pain)
  • first line: Morphine remains the drug of choice
    
    
    • gain control of pain
      • 'Immediate' release morphine (elixir or tablets) gives greatest flexibility for dose titration
      • starting dose 5-10mg morphine 4 hrly i.e. 6 x daily, (5mg for opioid naive patients; in the elderly or those with renal impairment use smaller doses e.g. 2.5mg four-hourly, with close monitoring). Additional prn doses at the same starting dose may be prescribed
      • titrate the dose to achieve pain relief by 30 - 50% increments in dose every 2-3 days or sooner if necessary - the latest update of the West Midlands guidance states that, if required, increases in analgesia should be done daily ".. titrate the dose to achieve pain relief by increasing in 30 - 50% increments per day.." (2)
        • reassess pain control daily
        • a 'log' of treatment kept by patients and carers is helpful in titration
      • there is no 'maximum' dose if pain is morphine responsive
      • specialist palliative care advice should be sought in the following circumstances:
        • rapidly escalating dose of morphine
        • morphine exceeds 300mg in 24 hours
        • if the patient develops adverse effects e.g. opioid toxicity (signs are respiratory depression, increasing drowsiness, confusion, myoclonic jerks)
      • in patients with less severe pain, or where circumstances dictate, morphine may be initiated as a modified release preparation at the appropriate dose
      • always prescribe a laxative when initiating opioid and continue to review bowel habit
        
        
    • maintenance
      • once pain is controlled there is a choice of options for maintenance:
        • continue regular immediate release morphine
        • change to 12 hourly modified release morphine
      • patients on modified release opioids should always have available immediate release opioid prescribed p.r.n. for episodes of breakthrough pain.
      • recommended dose of normal release opioid (usually morphine) for breakthrough pain is the equivalent of up to one sixth of the total 24-hour opioid dose
      • if the regular dose of opioid is increased, ensure that the breakthrough dose is increased appropriately
      • incident pain may require faster acting analgesia
      • ensure patients and their carers understand the use of the opioids they are taking and that doses are reviewed regularly
        
        
    • if further pain develops
      • reassess cause of pain and treat appropriately
      • if there is consistent need for frequent breakthrough analgesia, and the pain is opioid sensitive, increase the total daily opioid dose by 30 -50% and reassess
      • if the proposed dose increase is greater than 30 -50% seek advice from specialist palliative care

When prescribing opiates:

• a laxative is essential in most cases
• an anti-emetic may be needed for the first 3-7 days
• any initial sedation or confusion usually settles within 3-5 days (if not, change drug or seek advice)
• supplementary analgesia for breakthrough pain should always be available
• there is no upper dose limit but check why pain is uncontrolled
• co-analgesics (NSAID's, steroids, anti-depressants etc) may be needed especially in neuropathic and bone pain
• ring Hospice staff or Macmillan nurses for help with medication in palliative care. They are much more familiar with them than the GP is likely to be

Notes:

• NICE have given guidance regarding use of opioids in palliative care (3)- the guidance provides general principles about use of opioids in palliative care. The use of oral morphine preparations is the first line treatment. Also NICE suggest a typical daily starting dose
  • starting strong opioids - titrating the dose
    • when starting treatment with strong opioids, offer patients with advanced and progressive disease regular oral sustained-release or oral immediate-release morphine (depending on patient preference), with rescue doses of oral immediate-release morphine for breakthrough pain
    • for patients with no renal or hepatic comorbidities, offer a typical total daily starting dose schedule of 20-30 mg of oral morphine (for example, 10-15 mg oral sustained-release morphine twice daily), plus 5 mg oral immediate-release morphine for rescue doses during the titration phase
    • adjust the dose until a good balance exists between acceptable pain control and side effects. If this balance is not reached after a few dose adjustments, seek specialist advice. Offer patients frequent review, particularly in the titration phase
    • seek specialist advice before prescribing strong opioids for patients with moderate to severe renal or hepatic impairment
  • first-line maintenance treatment
    • offer oral sustained-release morphine as first-line maintenance treatment to patients with advanced and progressive disease who require strong opioids
    • do not routinely offer transdermal patch formulations as first-line maintenance treatment to patients in whom oral opioids are suitable
    • if pain remains inadequately controlled despite optimising first-line maintenance treatment, review analgesic strategy and consider seeking specialist advice
  • first-line treatment if oral opioids are not suitable - transdermal patches
    • consider initiating 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 microgram patch equates to approximately 45 mg oral morphine daily
      • a transdermal buprenorphine 20 microgram patch equates to approximately 30 mg oral morphine daily
  • first-line treatment for breakthrough pain in patients who can take oral opioids
    • offer oral immediate-release morphine for the first-line rescue medication of breakthrough pain in patients on maintenance oral morphine treatment
    • do not offer fast-acting fentanyl as first-line rescue medication
    • if pain remains inadequately controlled despite optimising treatment, consider seeking specialist advice

Reference:

1. West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control.
2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.
3. NICE (August 2016). Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults