Palliative care prescribing: pain


NICE guidelines

In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.

Starting treatment
•when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
•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
•oral modified-release morphine should be used in preference to transdermal patches
•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

SIGN guidelines

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
•the breakthrough dose of morphine is one-sixth the daily dose of morphine
•all patients who receive opioids should be prescribed a laxative
•opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
•metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Other points

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

Opioid side-effects

Usually transient

Usually persistent

Nausea
Drowsiness Constipation

Conversion between opioids

From

To

Conversion factor

Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10*

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

From

To

Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2**

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.

From

To

Conversion factor

Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*this has previously been stated as 5 but the current version of the BNF states a conversion of 10

**historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF however uses a conversion rate of 1.5

Palliative care prescribing: pain

NICE guidelines

In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.

Starting treatment
•when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
•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
•oral modified-release morphine should be used in preference to transdermal patches
•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

SIGN guidelines

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
•the breakthrough dose of morphine is one-sixth the daily dose of morphine
•all patients who receive opioids should be prescribed a laxative
•opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
•metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Other points

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

Opioid side-effects

Usually transient

Usually persistent

Nausea
Drowsiness Constipation

Conversion between opioids

From

To

Conversion factor

Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10*

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

From

To

Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2**

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.

From

To

Conversion factor

Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*this has previously been stated as 5 but the current version of the BNF states a conversion of 10

**historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF however uses a conversion rate of 1.5

Palliative care prescribing: pain

NICE guidelines

In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.

Starting treatment
•when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
•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
•oral modified-release morphine should be used in preference to transdermal patches
•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

SIGN guidelines

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
•the breakthrough dose of morphine is one-sixth the daily dose of morphine
•all patients who receive opioids should be prescribed a laxative
•opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
•metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Other points

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

Opioid side-effects

Usually transient

Usually persistent

Nausea
Drowsiness Constipation

Conversion between opioids

From

To

Conversion factor

Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10*

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

From

To

Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2**

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.

From

To

Conversion factor

Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*this has previously been stated as 5 but the current version of the BNF states a conversion of 10

**historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF however uses a conversion rate of 1.5

Palliative care prescribing: pain

NICE guidelines

In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.

Starting treatment
•when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
•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
•oral modified-release morphine should be used in preference to transdermal patches
•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

SIGN guidelines

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
•the breakthrough dose of morphine is one-sixth the daily dose of morphine
•all patients who receive opioids should be prescribed a laxative
•opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
•metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Other points

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

Opioid side-effects

Usually transient

Usually persistent

Nausea
Drowsiness Constipation

Conversion between opioids

From

To

Conversion factor

Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10*

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

From

To

Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2**

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.

From

To

Conversion factor

Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*this has previously been stated as 5 but the current version of the BNF states a conversion of 10

**historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF however uses a conversion rate of 1.5

Palliative care prescribing: pain

NICE guidelines

In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.

Starting treatment
•when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
•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
•oral modified-release morphine should be used in preference to transdermal patches
•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

SIGN guidelines

SIGN issued guidance on the control of pain in adults with cancer in 2008. Selected points
•the breakthrough dose of morphine is one-sixth the daily dose of morphine
•all patients who receive opioids should be prescribed a laxative
•opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred
•metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy

Other points

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

Opioid side-effects

Usually transient

Usually persistent

Nausea
Drowsiness Constipation

Conversion between opioids

From

To

Conversion factor

Oral codeine Oral morphine Divide by 10
Oral tramadol Oral morphine Divide by 10*

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

From

To

Conversion factor

Oral morphine Oral oxycodone Divide by 1.5-2**

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.

From

To

Conversion factor

Oral morphine Subcutaneous diamorphine Divide by 3
Oral oxycodone Subcutaneous diamorphine Divide by 1.5

*this has previously been stated as 5 but the current version of the BNF states a conversion of 10

**historically a conversion factor of 2 has been used (i.e. oral oxycodone is twice as strong as oral morphine). The current BNF however uses a conversion rate of 1.5

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.