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Guidance

Opioid prescribing in palliative care

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NICE guidance on prescribing strong opioids for pain relief in palliative care stresses the importance of communication.

Hundreds of thousands of people in the UK live with long-term or incurable illnesses for which strong opioids may be the only effective method of pain relief, yet these drugs remain underused. The National Institute for Health and Clinical Excellence (2012) has published its first clinical guideline on prescribing strong opioids as a first-line treatment for people receiving palliative care.

The focus of this much-needed guideline is reversing the situation and providing consistent advice to the NHS on the safe and effective prescribing of strong opioids. It aims to educate patients and prescribers about the safe use of these drugs, and dispel some of the myths about strong opioid use, such as those around fear of addiction.

It is worth noting that the guideline focuses on first-line treatment only, and does not cover second-line treatment where a change in strong opioid treatment is needed because of inadequate pain control or significant toxicity.

Legislative changes

Legislation in April 2012 has enabled appropriately qualified nurses to prescribe any schedule 2-5 controlled drugs for any medical condition within their clinical competence. This guideline, therefore, is relevant to nurses as well as doctors, pharmacists and palliative care specialists.

Palliative care

Patients receiving palliative care are not just those approaching their last few days of life. The Liverpool Care Pathway makes recommendations for caring for terminally ill patients who are close to death and the NICE guideline is entirely separate from this.

Instead, it is concerned with people living with long-term conditions such as heart failure (of whom there are around 900,000 in the UK) or those with kidney, respiratory or neurodegenerative conditions, such as motor neurone disease. There are also around 300,000 people diagnosed with cancer each year in the UK who may need palliative care.

For this group, strong opioids may be the only effective form of pain relief. However, treatment is inconsistent. Nurses or other health professionals may not always be sure about when to prescribe certain types of opioids and patients can worry about the long-term use of these drugs.

Key advice

The guideline makes recommendations in a number of areas, including:

  • Communication: when offering patients strong opioids, ask them about concerns such as addiction, tolerance, side-effects and fears that treatment implies the final stages of life. Offer them frequent reviews of pain control and side-effects, and information on who to contact out of hours, particularly during initiation of treatment;
  • Starting treatment: 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. The guidance contains details on dose scheduling;
  • First-line maintenance therapy: offer oral sustained-release morphine as first-line maintenance therapy to people with advanced and progressive disease who need strong opioids. If pain remains uncontrolled despite optimising first- line therapy, review analgesic strategy and consider seeking specialist advice.

Side-effects

Opioids are associated with side-effects such as constipation, nausea and drowsiness. The new guideline makes recommendations for health professionals, including nurses, to help them inform patients and treat these adverse effects. These include:

  • Informing patients that constipation affects nearly all those receiving strong opioid treatment, and prescribing laxative treatment (to be taken regularly) for all patients starting strong opioids;
  • Advising patients that nausea, mild drowsiness or impaired concentration may occur when starting opioid therapy or at dose increase, but that these effects are most likely to be transient.

Resources

To help put these recommendations into practice, NICE has produced a range of tools for practitioners in primary and acute care. These include a training package suitable for small-group learning, which includes clinical case scenarios for primary and acute care, PowerPoint slides and pre- and post-workshop quizzes. Written by practising clinicians, the cases show how to apply the recommendations in routine practice, while taking account of aspects of individualised care.

Key issues are also discussed in a podcast, including: significant changes for prescribers; how patient concerns about strong opioids should be addressed; why the guideline recommends the use of morphine as first-line treatment; and the likely side-effects of taking strong opioids and how these can best be managed.

The guideline, supporting materials, a costing report for commissioners and an audit tool can all be downloaded from here.

  • Anna-Marie Stevens is Macmillan nurse consultant in cancer and palliative care, Royal Marsden Foundation Trust, London; Catherine Piggin is clinical nurse specialist lead palliative care, Prospect Hospice, Swindon.
  • Click here for a print-friendly PDF of this article 
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