Pain management

Scottish Palliative Care Guidelines
Healthcare Improvement Scotland

This guideline relates to the management of pain in adult patients with palliative care needs.

Assessment

  • Assess pain fully before treatment (refer to Pain assessment guideline).
  • Consider reversible causes.
  • Ask the patient regularly about their pain control.
  • Record pain intensity scores. Use a pain assessment tool.

Management

Step 1: mild intensity pain

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paracetamol
1g four times daily

or non-steroidal anti-inflammatory drug (NSAID)
(if not contra-indicated – refer to "Adjuvant therapies" section below)

±other adjuvant
  • Consider reducing paracetamol dose to 500mg four times daily when poor nutritional status, low body weight (<50kg), hepatic impairment and/or chronic alcohol abuse (check local policy for paracetamol and NSAIDs if patient receiving chemotherapy).

 

Step 2: mild to moderate intensity pain

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weak opioid
Codeine 30mg to 60mg four times daily or dihydrocodeine 30mg to 60mg four times daily Alternative: use a combined paracetamol codeine preparation such as co-codamol 30/500, 2 tablets four times daily (refer to notes above about restrictions)		 + paracetamol
(Dose as above,
If no benefit stop after 3 to 4 days)		 or NSAID
(If not contra‑indicated)		 ± other adjuvant
  • Prescribe a laxative and consider anti-emetic

 

Step 3: moderate to severe intensity pain

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strong opioid + paracetamol
(Dose as above)
(stop if no benefit)		 or NSAID
(if not contra-indicated)		 ± other adjuvant
Stop any step 2 opioid
Codeine or dihydrocodeine 60mg 4 times daily≈24mg oral morphine in 24 hours		 Seek advice: severe pain not responding to treatment:
  • unacceptable side effects or toxicity
If titrating with immediate release oral morphine prescribe 5mg, 4 hourly and as required for breakthrough pain If starting with modified release oral morphine prescribe 10mg to 15mg,
12 hourly and immediate release morphine 5mg as required for breakthrough pain
  • Consider prescribing a laxative and anti-emetic.
  • Use lower doses and increase dose more slowly if patient is frail, elderly or has renal impairment.
  • In severe renal impairment, an alternative opioid may be needed (refer to Choosing and changing opioids guideline).

Dose titration for Step 3

(using morphine as an example)

  • Increase regular oral morphine dose each day in steps of about 30% (or according to breakthrough doses used) until pain is controlled or side effects develop.
  • Increase laxative dose as needed.
  • Convert to modified release morphine when stable.
    • Divide 24 hour dose of immediate release morphine by 2.
    • Prescribe as modified release morphine, 12 hourly.
    • Prescribe breakthrough analgesia at correct dose (1/6th to 1/10th of 24 hour morphine dose up to a maximum of 6 doses in 24 hours).

 

Anti-emetic Regular laxative (refer to Constipation guideline)
QTMetoclopramide 10mg up to three times a day Senna 2 tablets at night or bisacodyl 5mg to 10mg at night plus docusate 100mg twice daily
QTHaloperidol 500 micrograms to 1.5mg daily Prescribe as required for 5 to 10 days Macrogol 1 to 3 sachets per day

 

Other management considerations

Subcutaneous (SC) analgesia

  • Usually given via a syringe pump over 24 hours.
  • Calculate the 24 hour dose of oral morphine.
  • Convert this to SC morphine.
  • Oral morphine 30mg≈SC morphine 15mg.
  • When large doses of breakthrough SC analgesia are required consider SC diamorphine.
  • Prescribe 1/6th to 1/10th of the 24 hour SC opioid dose as required, via SC route for breakthrough pain.
  • Refer to Syringe pumps guideline.

Breakthrough pain

Defined as a transient exacerbation of pain which occurs either spontaneously or in relation to a specific trigger (incident pain) in someone who has mainly stable or adequately relieved background pain.

  • Prescribe immediate release morphine at 1/6th to 1/10th of the regular 24 hour dose, as required up to a maximum of 6 doses in 24 hours. If 3 or more doses have been given within 4 hours with little or no benefit seek urgent advice or review. If more than 6 doses are required in 24 hours seek advice or review.
  • Assess 30 to 60 minutes after a breakthrough dose.
  • If pain persists give a second dose as required.
  • If pain is still not controlled seek advice.
  • Change breakthrough dose if regular dose altered.

Movement or incident related predictable pain

Can be difficult to manage; a dose of short-acting opioid before moving or when pain occurs may help. If pain is short-lived and the patient develops excessive drowsiness seek specialist advice.

Opioid toxicity – seek advice

  • Can be precipitated by several factors including rapid dose escalation, renal impairment, sepsis, electrolyte abnormalities, drug interactions.
  • Wide variation in the dose of opioid can cause symptoms of toxicity.
  • Prompt recognition and treatment are needed. Symptoms include:
    • persistent sedation (exclude other causes)
    • vivid dreams, hallucinations, shadows at the edge of visual field
    • delirium
    • muscle twitching/myoclonus/jerking
    • abnormal skin sensitivity to touch.
  • If the pain is controlled reduce the opioid dose by a third. Ensure the patient is well hydrated. Seek advice.
  • If patient still in pain consider reducing opioid dose by a third. Consider adjuvant analgesics, alternative opioids or both (refer to Choosing and changing opioids guideline). Seek advice.
  • Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression (refer to Naloxone guideline).

 

Adjuvant therapies

  • NSAID: for bone pain, liver pain, soft tissue infiltration, or inflammatory pain (side effects: gastrointestinal ulceration or bleeding [consider proton pump inhibitor (PPI)], renal impairment, fluid retention, adverse cardiac events).
  • Antidepressant or anticonvulsant: for nerve pain. Start at low dose: titrate slowly (refer to Neuropathic pain guideline). No clear difference in efficacy between the two types of medicine for this indication.
    • amitriptyline (side effects: confusion, hypotension caution in cardiovascular disease).
    • gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).
    • amitriptyline (side effects: confusion, hypotension caution in cardiovascular disease).
    • gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment).
  • Corticosteroids: †dexamethasone
    • 8mg to 16mg daily for raised intracranial pressure.
    • 4mg to 8mg daily for neuropathic pain; 4mg to 8mg daily for liver capsule pain.
    • Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.
    • 8mg to 16mg daily for raised intracranial pressure.
    • 4mg to 8mg daily for neuropathic pain; 4mg to 8mg daily for liver capsule pain.
    • Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose.
  • TENS, nerve block, radiotherapy, surgery, bisphosphonates, ketamine  (specialist use) and skeletal or smooth muscle relaxants.

Practice points

When prescribing regular analgesia for continuous pain, discuss and resolve any concerns about taking opioids, including:

  • addiction
  • tolerance
  • short and long term side effects
  • fears that treatment implies the final stages of life.

Provide information (verbal and written) to the patient:

  • when and why strong opioids are used to treat pain
  • how effective they are likely to be
  • background and breakthrough pain management
  • signs of toxicity
  • strong pain killers and driving, refer to NHS Inform page on driving
  • follow up plans

Resources

References

Bennett MI. Effectiveness of antiepileptic or antidepressant drugs when added to opioids for cancer pain: systematic review. Palliat Med. 2011;25(5):553-9.

Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):e58-68.

Caraceni A, Pigni A, Brunelli C. Is oral morphine still the first choice opioid for moderate to severe cancer pain? A systematic review within the European Palliative Care Research Collaborative guidelines project. Palliat Med. 2011;25(5):402-9.

Cherny N. Is oral methadone better than placebo or other oral/transdermal opioids in the management of pain? Palliat Med. 2011;25(5):488-93.

Dale O, Moksnes K, Kaasa S. European Palliative Care Research Collaborative pain guidelines: opioid switching to improve analgesia or reduce side effects. A systematic review. Palliat Med. 2011;25(5):494-503.

Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G. The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain. 2009;13(4):331-8.

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Forbes K. Pain in patients with cancer: the World Health Organization analgesic ladder and beyond. Clin Oncol (R Coll Radiol). 2011;23(6):379-80.

Haugen DF, Hjermstad MJ, Hagen N, Caraceni A, Kaasa S. Assessment and classification of cancer breakthrough pain: a systematic literature review. Pain. 2010;149(3):476-82.

King SJ, Reid C, Forbes K, Hanks G. A systematic review of oxycodone in the management of cancer pain. Palliat Med. 2011;25(5):454-70.

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Maltoni M, Scarpi E, Modonesi C, Passardi A, Calpona S, Turriziani A, et al. A validation study of the WHO analgesic ladder: a two-step vs three-step strategy. Support Care Cancer. 2005;13(11):888-94.

Mercadante S, Caraceni A. Conversion ratios for opioid switching in the treatment of cancer pain: a systematic review. Palliat Med. 2011;25(5):504-15.

Pigni A, Brunelli C, Caraceni A. The role of hydromorphone in cancer pain treatment: a systematic review. Palliat Med. 2011;25(5):471-7.

Radbruch L, Trottenberg P, Elsner F, Kaasa S, Caraceni A. Systematic review of the role of alternative application routes for opioid treatment for moderate to severe cancer pain: an EPCRC opioid guidelines project. Palliat Med. 2011;25(5):578-96.

Tassinari D, Drudi F, Rosati M, Maltoni M. Transdermal opioids as front line treatment of moderate to severe cancer pain: a systemic review. Palliat Med. 2011;25(5):478-87.

Tassinari D, Drudi F, Rosati M, Tombesi P, Sartori S, Maltoni M. The second step of the analgesic ladder and oral tramadol in the treatment of mild to moderate cancer pain: a systematic review. Palliat Med. 2011;25(5):410-23.

Tessaro L, Bandieri E, Costa G, Fornasier G, Iorno V, Pizza C, et al. Use of oxycodone controlled-release immediately after NSAIDs: a new approach to obtain good pain control. Eur Rev Med Pharmacol Sci. 2010;14(2):113-21.

Zeppetella G. Opioids for the management of breakthrough cancer pain in adults: a systematic review undertaken as part of an EPCRC opioid guidelines project. Palliat Med. 2011;25(5):516-24.