Pain is a symptom people associate with a malignant illness and is common in non malignant disease.

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1 HAWKE S BAY DISTRICT HEALTH BOARD Manual: Clinical Guidelines Manual CRANFORD HOSPICE Doc No: HBDHB/IVTG/139 Issue Date: Review Date: 3 yearly Approved: Cranford Hospice Medical Pain in the Palliative Care Setting Director Signature: Page: 1 of 7 PURPOSE To guide the management of pain in the palliative care setting. SCOPE Medical and nursing staff managing the palliative patient. PRINCIPLES Pain is a symptom people associate with a malignant illness and is common in non malignant disease. Pain may also be due to pre-existing disease, e.g. arthritis, angina, gallstones. Fear of escalating pain can be overwhelming. Uncontrolled pain alters one s ability to cope with other stresses and can contribute to sleeplessness, depression, nausea, loss of mobility and social limitations. If/when an opioid is needed, morphine is the gold standard. ASSESSMENT Thorough assessment is a prerequisite for effective pain control because: It is important to identify treatable underlying contributors, such as Constipation, infection, pathological fractures Unaddressed fear or depression Some drugs are effective for some pain types and not others Pain is a complex human experience influenced by factors other than nociceptive nerve activity Identifying and treating only biological contributions to a person s pain is a common reason for ineffective pain control 4 It is common to have more than one type of pain present, therefore combinations of therapies/drugs may be more effective than single agents Some common pain types include: Nociceptive Pain (pain associated with tissue distortion or injury) Often described as an ache, discomfort, soreness, dull or deep pain. Includes superficial pain (e.g. pressure areas, mouth ulcers), deep visceral organ pain (e.g. liver capsule pain), or solid tumour pain.

2 Pain in the Palliative Care Setting Page 2 of 7 Neuropathic Pain (pain associated with central and/or peripheral nerve damage) Often described as shooting, burning or radiating. Associated with sensory changes and neurological signs e.g. tingling, numbness or weakness. Bone Pain Often characterised by localised pain that is worse with movement or weight bearing. Smooth muscle spasm Often described as gripey, crampy or comes in waves e.g. colic secondary to constipation or bowel obstruction. Total Pain Total pain is a term used in palliative care to describe the pain that encapsulates some or all of the realms of physical, psychosocial, emotional and spiritual pain 4. (See Table 1). MANAGEMENT The assessment includes establishing the patient s priorities. Management is holistic and not limited to medications (see examples below). Table 1: Non Pharmacological Management Faith Support Exploration of issues Heat/cold therapy Massage TENS Wairua SPIRITUAL Beliefs Value systems Fear of death Helplessness Tinana PHYISCIAL Weakness/ debility Nausea / vomiting Constipation Therapy side effects Fatigue and insomnia Disfigurement Hinengaro PSYCHOLOGICAL Anger Guilt Sense of loss Lack of understanding Loss of dignity Whanau FAMILY AND SOCIAL Worry about family, finances, the future. care issues Good communication, freedom to ask questions Relaxation and/or distraction techniques Consider referral to Cranford Hospice Family Support Team Exploration of issues Consider social work referral

3 Pain in the Palliative Care Setting Page 3 of 7 Table 2: Pharmacological Management (Adapted from the WHO analgesic ladder 1 ) Paracetamol +/- Non-Steroidal Anti Inflammatory Drug (NSAID) ADD Codeine or Dihydrocodeine (+/- NSAID) EXCHANGE PRN morphine helpful. Tolerating morphine Morphine (+/- NSAID) PRN morphine unhelpful Morphine adverse effects Titrate morphine Adjuvant analgesics D/W specialist palliative care team re: options Oral administration is preferable Prescribe analgesics to be given regularly and titrate according to the individual needs Adjuvant Analgesics: PAIN TYPE DRUG FAMILY Nociceptive pain, bone pain - NSAIDs Tumour compression, liver capsule pain, soft tissue infiltration - Corticosteriods Neuropathic pain - Anti-depressants, anti-epileptics Muscle spasm, myofacial pain - Skeletal muscle relaxant Visceral distention pain, colic - Smooth muscle relaxant Muscle spasm, anxiety related - Benzodiazepines Bone - Bisphosphonates OPIOID PRESCRIBING Note: Driving and opioids: Opioids do not prevent a person from driving per se. Every individual driver has a responsibility to ensure they are safe to drive a vehicle. Healthcare professionals must advise patients if treatment can affect their driving skills. For most patients, they should not drive within a week of starting opioid therapy, or within 3 days of increasing the dose, or if they suffer drowsiness and/or confusion. Further information is available NZ Transport Authority. (2009). Medical aspects of fitness to drive; a guide for medical practitioners. NZTA: Palmerston North Initiating morphine Either use short acting morphine 5mg Q4H regularly or use long acting morphine BD (e.g. m-eslon 10mg PO BD) Use short acting morphine 2.5 to 5mg q4h PRN for break through pain PRN doses of morphine are typically 1/6 of the regular 24 hour dose Dose interval for short acting morphine is q4h; closer intervals may be required when pain is severe or patient is in the last days of life

4 Pain in the Palliative Care Setting Page 4 of 7 Dose titration If pain is not controlled, i.e. 2 or more break through doses of analgesia needed per day for consecutive days, increase m-eslon dose by 30-50% This applies only after the first 24 hours of the regular dose i.e. on day 2 or 3 or later Renal impairment and the elderly Use lower doses with the frail elderly e.g.1 to 2.5mg In renal failure fentanyl is the opioid of choice If the egfr <30, fentanyl is indicated (see HBDHB/IVTG911) Pain not responding to opioid If increasing doses of opioid do not improve pain consider if the opioid is the right drug, at the right dose and via the right route Before increasing the dose or changing opioids consider whether adjuvant analgesia would be beneficial 2 Side effects of opioids and management All opioids are associated with the following adverse effects but the incidence and severity vary from opioid to opioid. - Constipation a laxative should be prescribed prophylactically with the first prescription of the opioid e.g. Laxsol (Sennosides 8mg & Docusate Sodium 50mg) 1-2 tabs OD (see HBDHB/IVTG/903) - Nausea/vomiting usually in the first few days until tolerance develops e.g. Haloperidol mg nocte (see HBDHB/IVTG/908) - Drowsiness usually in the first few days following introduction and when doses are increased, until tolerance develops - The following side effects merit discussion with specialist palliative care service: o Confusion, cognitive blunting o Hallucinations, o Itch o Hyperalgesia (increased pain; at its most severe it can be allodynia pain in the absence of a painful stimulus) CHANGING FROM ONE STRONG OPIOID TO ANOTHER Discuss with a palliative care specialist Indications: When pain is responsive to an opioid but increasing the dose is limited by side effects that do not respond to the above measures When increased dose is not effective and adjuvant analgesics have been considered and are ineffective When pain control is stable, but the transdermal route is more suitable than the oral route Close monitoring for effect and side effects is needed during and for the first 48 hours after any change of opioid as conversion ratios are only a guide: An over-estimation will give undue drowsiness, or other side effects, and no need for PRN doses and an under-estimation will give insufficient pain relief and on-going requests for PRN doses

5 Pain in the Palliative Care Setting Page 5 of 7 Table 3: Converting oral morphine to another opioid The new opioid Oxycodone oral Fentanyl TD patch Methadone Action Half the total daily dose of morphine (e.g. meslon 30mg BD = Oxycontin 15mg BD) Refer to IVTG/911 Fentanyl Transdermal Patch in the palliative context Contact specialist palliative care Table 4: Other common opioid conversions APPROXIMATE DOSE CONVERSION RATIOS CONVERSION RATIO CALCULATION EXAMPLE Codeine PO to morphine PO 10:1 Divide 24 hour dose codeine by 10 Codeine 240mg/24 hours PO = morphine 24mg/24 hours PO (round up or down according to patient need) Morphine PO to morphine subcut 2:1 Divide morphine dose by 2 Morphine 10mg PO = 5mg subcut Morphine 60mg/24 hours PO = morphine 30mg/24 hours subcut (CSCI*) Oxycodone PO to oxycodone subcut 2:1 Divide oxycodone dose by 2 Oxycodone 10mg PO = 5mg subcut Oxycodone 60mg/24 hours PO = oxycodone 30mg/24 hours subcut (CSCI) Morphine subcut to oxycodone subcut 1:1 The dose of subcut morphine is the same as subcut oxycodone. Morphine 10mg subcut = Oxycodone 10mg subcut Morphine 60mg/24 hours subcut = oxycodone 60mg subcut/24hrs (CSCI) Morphine SC to fentanyl variabl e n/a Contact specialist palliative care * CSCI = Continuous Subcutaneous Infusion (Syringe Pump) REFERENCES 1. Twycross, R.G. & Wilcock, A. (2007). Palliative care formulary 4 th ed: PCF4. Nottingham. Oxford. New York: Radcliff Medical Press. 2. Dale, O., Moksnes, K. & Kaasa, S. (2010). European palliative care research collaborative pain guidelines: Opioid switching to improve analgesia or reduce side effects. A systemic review. Palliaitve Medicine. 25(5):

6 Pain in the Palliative Care Setting Page 6 of 7 3. Mercandante, S. & Caraceni, A. (2011). Conversion ratios for opioid switching in the treatment of cancer pain: a systemic review. Palliative Medicine. 25(5): MacLeod, R. (2007). Total pain physical, psychological and spiritual. Goodfellow Symposium As retrieved from: 5. Ministry of Transport. (2013). Questions and answers on law to combat drug impaired driving Schisler, R.R., Groninger, H. & Rosielle, D.A. (2012). Counselling patients on side effects and driving when starting opioids. Journal of Palliative Medicine. 15(4): RELATED DOCUMENTS Constipation prescribing in the palliative context HBDHB/IVTG/903 Nausea & Vomiting in the palliative context HBDHB/IVTG/908 Naloxone use for opioid toxicity in the palliative or terminal context HBDHB/IVTG/908 Fentanyl Transdermal Patch in the palliative context HBDHB/IVTG/911 KEYWORDS Analgesia Codeine Fentanyl Morphine Opioid Oxycodone Pain Palliative Paracetamol Transdermal For further information please contact the Specialist Palliative Care Service. DISCLAIMER Every effort has been made to ensure the accuracy of the content using the best information available at the time of publishing. The use of these guidelines does not diminish the requirement for the health professional to exercise their clinical judgement. It is the responsibility of the health professional using these guidelines to adapt them for use in line with your own service policies taking into account individual patients needs. Accordingly PSEC, Cranford Hospice, Hawkes Bay Hospital, the publishers or the authors do not accept responsibility for any errors, omissions in the guidelines; or any liability for loss, damage or negligence which may directly or indirectly result form the use of the guidelines in practice.

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