Palliative Care for Adults: Strong Opioids for Pain Relief

NICE decides that the guidance CG140 should be transferred to the static list and checked for the need for an update at 5-year intervals or if new evidence emerges

The NICE 'Palliative care for adults: strong opioids for pain relief' guideline offers evidence-based advice on safe and effective prescribing of strong opioids for pain relief in adults with advanced and progressive disease.

NICE reviewed the guideline and decided that it should not be updated at this time and the guidance should be transferred to the static list. Guidelines on the static list will remain extant and will be checked for the need for an update at 5-year intervals, or if new evidence emerges. The next review date is set for 2021.

In August 2016, recommendation 1.1.12 was deleted and a link added to NICE’s guideline on 'Controlled drugs: safe use and management,' which has more recent advice on the topic. Two out-of-date research recommendations were also removed.

This guideline was previously called 'Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults.'

Pain is common in advanced and progressive disease. Up to two-thirds of people with cancer experience pain that requires a strong opioid. This proportion is similar or higher in many other advanced and progressive conditions.

Despite the increased availability of strong opioids, published evidence suggests that pain which results from advanced disease, especially cancer, remains under-treated. The 2008 World Cancer Declaration included a target to make effective pain control more accessible. Several key documents highlight the importance of effective pain control.

Strong opioids, especially morphine, are the principal treatments for pain related to advanced and progressive disease, and their use has increased significantly in the primary care setting. However, the pharmacokinetics of the various opioids are very different and there are marked differences in bioavailability, metabolism and response among patients. A suitable opioid must be selected for each patient and, because drug doses cannot be estimated or calculated in advance, the dose must be individually titrated.

Effective and safe titration of opioids has a major impact on patient comfort. The World Health Organization has produced a pain ladder for the relief of cancer pain; strong opioids are represented on the third level of the three-step ladder.

The guideline will address first-line treatment with strong opioids for patients who have been assessed as requiring pain relief at the third level of the WHO pain ladder. It will not cover second-line treatment with strong opioids where a change in strong opioid treatment is required because of inadequate pain control or significant toxicity.

A number of strong opioids are licensed in the UK. However for pain relief in palliative care a relatively small number are commonly used. This guideline has therefore looked at the following drugs: buprenorphine, diamorphine, fentanyl, morphine and oxycodone.

Misinterpretations and misunderstanding have surrounded the use of strong opioids for decades, and these are only slowly being resolved. Until recently, prescribing advice has been varied and sometimes conflicting. These factors, along with the wide range of formulations and preparations, have resulted in errors causing underdosing and avoidable pain, or overdosing and distressing adverse effects. Despite repeated warnings from regulatory agencies, these problems have led on occasion to patient deaths, and resulted in doctors facing the General Medical Council or court proceedings. This guideline will clarify the clinical pathway and help to improve pain management and patient safety; it will not cover care during the last days of life.

The guideline assumes that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

Who this guideline is for

The target audience is non-specialist healthcare professionals initiating strong opioids for pain in adults with advanced and progressive disease. However, the guideline is likely to be of relevance to palliative care specialists as well.

Patient-centred care

This guideline offers best practice advice on the care of people with advanced and progressive disease, who require strong opioids for pain control. These patients are defined as those in severe pain who may be opioid-naive, or those whose pain has been inadequately controlled on step two of the WHO pain ladder.

Treatment and care should take into account patients' needs and preferences. People with advanced and progressive disease, who require strong opioids for pain control, should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health’s advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.

Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient's needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need.

The guideline recommendations cover the following:

  • Communication
  • Starting strong opioids – titrating the dose
  • First-line maintenance treatment
  • First-line treatment if oral opioids are not suitable – transdermal patches
  • First-line treatment if oral opioids are not suitable – subcutaneous delivery
  • First-line treatment for breakthrough pain in patients who can take oral opioids
  • Management of constipation
  • Management of nausea
  • Management of drowsiness

Read the full list of recommendations here.
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