Opioids should be used as part of a holistic, multidisciplinary approach to providing palliative care. The dying patient may find that non-pharmacological therapy provides relief in addition to opioid treatment.
There are a number of opioids available for use in managing pain in palliative care. Each has its own benefits. Whilst oral morphine is described as the gold standard approach to pain management in palliative care, since the publication of the European Association for Palliative Care (EAPC) guidelines, a number of new types and formulations of opioids have been made available providing greater choice, a greater range of benefits, and greater flexibility for both patients and physicians.
Initiating opioid therapy in palliative care
Depending on the opioid used, titration up to pain control can be undertaken through the use of immediate release preparations given every 4 hours, with additional provision made for managing breakthrough pain. The rescue dose may be given as often as required (4 - 6 hours) and the total daily dose should be reviewed daily. This will continue until the patient's pain is controlled. If pain returns consistently before the next regular dose is due, the regular dose should be increased. In general, immediate release opioids do not need to be given more than every 4 hours, and prolonged release opioids more than 12 or 24 hours (according to the intended duration of the formulation). Patients stabilised on regular oral opioids require continued access to a rescue dose to treat breakthrough pain. Patients are also often started on long-acting oral opioids and use immediate release preparations for rescue analgesia.
A patient's drug regimen should be as simple as possible, because increasing the frequency of administration may cause distress and confusion, and subsequently may adversely affect compliance and convenience for the patient. Titration guidelines are not, however, set in stone, for patients receiving immediate release morphine every 4 hours, a double dose at bedtime is a simple and effective way of avoiding broken sleep due to pain. While no formal investigation into this practice has taken place, it has been widely adopted and does not appear to cause problems.
A wide range of opioids in different doses and formulations should be available and accessible to prescribers in each country to ensure optimal pain management. Not all patients get adequate analgesia from the same opioid, e.g. up to 30% of patients cannot tolerate morphine due to adverse side effects.
In its 2003 report, the International Narcotics Control Board1 called for countries to ensure that their efforts to control the use of opioids does not negatively impact the management of pain. In addition, the Council of Europe report on palliative care, makes specific recommendations to the governments of each of the 45 member states.
“Legislation should make opioids and other drugs accessible in a range of formulations and dosages for medical use. The fear of abuse should not hinder the access to necessary and effective medications. Countries may wish to consider whether this will require new legislation or an amendment to existing legislation”.2
If patients are unable to take oral opioids, the preferred alternative route is subcutaneous. Generally, no indication for giving opioids intramuscularly for moderate to severe pain exists because subcutaneous administration is simpler and less painful. In patients who require continuous parenteral opioids, the preferred method of administration is by subcutaneous injection.
To read more about opioid use click on the links below:
1) International Narcotics Control Board, Annual Report, 2003; Available from : URL: http://www.incb.org/incb/en/annual_report_2003.html.
2) Available from: URL: http://www.coe.int/T/E/Social_Cohesion/Health/Recommendations/Rec%282003%2924.asp.