Palliative care

Question 1

What pain relief should initially be prescribed? What should be considered when prescribing these?

Answer 1

• Offer patients regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain (breakthrough dose is 1/6th of total daily dose)
• if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. For example, 15mg modified-release morphine tablets twice a day with 5mg of oral morphine solution as required
• laxatives should be prescribed for all patients initiating strong opioids
• patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
• drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
• opioids should be used with caution in patients with chronic kidney disease - oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment. If renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred

Question 2

How should metastatic bone pain be managed?

Answer 2

Metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy.

Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates*.

All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy

In addition to strong opioids, bisphosphonates and radiotherapy, denosumab may be used to treat metastatic bone pain

Question 3

How should the dose of pain relief be increased?

Answer 3

When increasing the dose of opioids the next dose should be increased by 30-50%.

Question 4

How should you convert oral codeine/tramadol to oral morphine?

Answer 4

Divide by 10

Question 5

How does oxycodone compare to morphine?

Answer 5

Oxycodone generally causes less sedation, vomiting and pruritis than morphine but more constipation.

Question 6

How should you convert oral morphine to oral oxycodone?

Answer 6

Divide by 1.5-2

Question 7

What are the transdermal fentanyl and buprenorphine patches equate to in oral morphine?

Answer 7

The current BNF gives the following conversion factors for transdermal perparations
a transdermal fentanyl 12 microgram patch equates to approximately 30 mg oral morphine daily
a transdermal buprenorphine 10 microgram patch equates to approximately 24 mg oral morphine daily.

Question 8

How do we convert oral morphine into:
* SC morphine
* SC diamorphine

Answer 8

• Divide by 2
• Divide by 3

Question 9

How do we convert oral oxycodone into:
* SC diamorphine

Answer 9

Divide by 1.5