opioid analgesia for acute pain management

Opioid Analgesia for Acute Pain Management Reference Number: Pha6(06)a Version Number: 3 Issue Date: 23/11/2018 of 25

It is your responsibility to check on the intranet that this printed copy is the latest version

Opioid Analgesia for Acute Pain Management

Lead Author: Fionn Murison (Highly Speciality Nurse )

Additional author(s) Dr Justin Turner, Pain Management Consultant, Clinical Lead.

Division/ Department:: Surgical Neurosciences

Applies to: (Please delete) Salford Royal Care Organisation

Date approved: 19/11/2018

Expiry date: November 2021

* This includes documents relevant to multiple Care Organisations, Corporate and Support Services

Contents

Contents

Section Page

Click here for the document summary sheet:

1 What is the policy about? 2

2 Where will this document be used? 2

3 Why is this document important? 3

4 What is new in this version? 4

5 What is the Policy*/Procedure*/Guideline*?

Opioid Analgesia and Formulary Recommendations

Codeine

Morphine

Oxycodone

Fentanyl

Buprenorphine

Tramadol

Pethidine- not used in SRFT

Entonox

Diamorphine

Using opioids in post-operative pain management

Adverse Effects of Opioid Analgesia Opioid Toxicity

Treatment of Opioid Toxicity (Naloxone)

Opioid Withdrawal

Opioid induced Hyperalgesia, Tolerance and dependency

5 -11 13 14 15

6 Roles and responsibilities 17

7 Monitoring document effectiveness 17

8 Abbreviations and definitions 17

9 References and Supporting Documents 18

10

Document Control Information 19

11

Equality Impact Assessment (EqIA) screening tool 21

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)



12

Appendices

Pain Assessment Tools

Analgesia Ladder

Clinical Opiate Withdrawal Scale (COWS)

23

1. What is this policy about?

All patients should have a pain assessment using an appropriate tool (Appendix1)

Analgesia should be prescribed according to pain assessment using the analgesia ladder

(Appendix 2)- check for existing prescriptions to avoid duplication!

Sustained release preparations, prescribed pre-admission, should be continued during a

patient’s admission, unless contraindicated, to prevent withdrawal and unrelieved pain.

Opioids should be prescribed for the management of moderate to severe pain as part of

a multimodal pain management strategy (Appendix 2)

The oral route should be used whenever possible,

Morphine is the analgesia of choice and should be used as first line strong opiate (for

moderate to severe pain) unless contraindicated.

Patients aged 70 years and over should be prescribed oxycodone for moderate to severe

acute pain.

Patients with renal impairment (AKI, Chronic renal failure) consider oxycodone for

moderate to severe pain.

Consider use of laxatives to address Opioid induced constipation

Intravenous opioid titration may be required prior to oral administration to establish blood

plasma concentration levels in acute pain. http://intranet/policies-resources/trust-policy-

documents/trust-wide-clinical/gen/345tdc85/

Post-Operative order sets are available for the prescribing of post-operative analgesia via

EPMAR.

The Post-Operative nausea and vomiting order set should be considered when

prescribing opioids.

Intravenous naloxone should be prescribed for the management of opioid toxicity.

For pre-operative review or advice regarding post-operative management please contact

the Inpatient Pain Team.

http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/345tdc85/




2. Where will this document be used?

• All clinical staff managing patients requiring oral analgesia for acute pain.

3. Why is this document important?

Opioids have a well-established role in the management of acute pain however, the need for on-going monitoring of treatment and identification and management of any problems related to opioid use must be considered. Patients should be advised of side-effects and the likelihood of experiencing them before commencing an opioid; 80% of patients taking opioids will experience at least one adverse effect. The most common side-effects of opioids include

nausea and vomiting (particularly in initial stages),

constipation,

dry mouth,

somnolence,

itching,

dizziness

biliary spasm

Larger doses may cause

muscle rigidity,

hypotension

Sedation and respiratory depression.

Tolerance to some side-effects usually occurs within the first few days of initiating treatment; however others including pruritus and constipation tend to persist. The National Patient Safety Agency (NPSA) has recommended that when prescribing, dispensing or administering opioids, the healthcare practitioner should:

Confirm any recent opioid dose, formulation, frequency of administration and other analgesia medication prescribed for the patient.

Ensure where a dose increase is intended, that the calculated dose is safe for the patient.

Check the usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, and common side-effects of that medicine and formulation.

Sustained release preparations, prescribed pre-admission, should be continued during a patient’s admission, unless contraindicated, to prevent withdrawal and unrelieved pain. Such preparations should not be used to manage episodes of acute pain or in patients whose analgesic requirements are changing rapidly, due to the delayed onset of analgesic effect. For pre-operative review or advice regarding post-operative management please contact the Inpatient Pain Team.



Long Term Opioid Use The British Pain Society (BPS) has produced a patient information leaflet (PIL) which should be given to patients when commencing on a long term opioid: Opioids for persistent pain: information for patients. https://www.rcoa.ac.uk/node/21133

4. What is new in this version?

4.1 Opioid administration advice: To consider lowest dose first when a dose range is prescribed

5. Policy*/Procedure*/ Guideline (*delete as appropriate)

The management of acute pain and trauma pain involves individual patient assessment and the use of balanced analgesia, often including opioid analgesia. The prescribing of opioids for acute pain requires a titration period to establish and then maintain analgesia. The lowest dose of opioid should always be considered when a dose range is prescribed. For post-operative pain management opioid analgesia along with appropriate adjuvants should be prescribed before or at the time of surgery to ensure they are available when they are needed. Many patients undergoing intermediate surgical procedures may manage well on a combination of Paracetamol and Codeine Phosphate +/- Non Steroidal Anti-Inflammatory Drugs (NSAID’s), however, patients undergoing a major surgical procedure are at risk of experiencing severe pain and strong opioid analgesia will be required. Mild opioids include: Codeine or Tramadol. Strong opioids include: Morphine, Diamorphine, Oxycodone, Methadone and Fentanyl. N.B Morphine is less suitable for those aged 70yrs and over as they have increased risk of side effects from metabolites. This patient group and those with renal impairment should be prescribed an alternative such as Oxycodone. Opioid Analgesia and formulary recommendations First-line Oral Mild Opioid: Codeine The oral route should be used whenever possible, when the patient is tolerating oral fluids. The response to medication should be monitored, and the dose titrated to effect. If analgesia is ineffective or not tolerated, consider the second line opioid, morphine. Codeine 60mg PO is equivalent to approximately 10mg morphine PO.

https://www.rcoa.ac.uk/node/21133



Codeine is partially metabolised by CYP2D6 and so an estimated 7% of the Caucasian population lacking/deficient in this enzyme will not obtain adequate analgesic effect. Conversely, up to 1-2% of the Caucasian population are ultra-rapid metabolisers and are therefore at increased risk of developing side effects of opioid toxicity even at low doses. CODEINE INDICATION mild to moderate pain PHARMACOKINETICS Onset of action 15-30 minutes, Peak ~ 1 hour, Duration 4-6 hours CAUTIONS impaired respiratory function (avoid in COPD) and asthma (avoid during acute attack), hypotension, urethral stenosis, shock, myasthenia gravis, prostatic hypertrophy, obstructive or inflammatory bowel disorders, diseases of the biliary tract, and convulsive disorders. A reduced dose is recommended in elderly or debilitated patients, in hypothyroidism, and in adrenocortical insufficiency. Caution is advised if prescribing for patients with a history of drug dependence. Avoid abrupt withdrawal after long-term treatment. CONTRA-INDICATIONS avoid in patients with acute respiratory depression; contra-indicated in patients with raised intracranial pressure and in head injury (opioid analgesics interfere with pupillary responses vital for neurological assessment). Comatose patients should not be treated with opioid analgesics. ROUTES use the oral route whenever possible, if the patient is tolerating oral fluids Oral: tablets, syrup IM: injection- rarely used, discuss with Pain Team DOSES Oral, adults: 30-60mg every 4 hours when necessary, to a max. 240mg daily DO NOT co-prescribe Tramadol and Codeine For complete information on any medicine please refer to the current BNF First Line Strong Opioid for moderate to severe pain: Morphine Morphine remains the most valuable opioid for severe pain, and the standard against which other opioids are compared, though it causes nausea and vomiting in up to 40% of patients. In addition to analgesia, morphine can also produce a state of euphoria and mental detachment. Initial treatment should be titrated against patient response, including relief of pain, and side-effects; if the patient continues to experiences pain following an adequate dose, a further dose may be given as outlined below



MORPHINE INDICATIONS Acute Postoperative/ Trauma Pain, severe and intractable (chronic) pain CAUTIONS see cautions for codeine; also pancreatitis, cardiac arrhythmias, severe cor pulmonale CONTRA-INDICATIONS see contraindications for codeine; also delayed gastric emptying, acute abdomen, heart failure secondary to chronic lung disease; phaeochromocytoma ROUTE Oral: Tablets, capsules, suspension, granules Injection: IV, SC, PCA, (intrathecal requires preservative free Morphine) DOSE: dependent on route and cause of pain; closely monitor pain relief and side-effects especially respiratory depression. ACUTE PAIN Oral, adults: 10-20mg Post-Operative Regimen to establish analgesia (EPMAR) 1hry for 3 doses then 3hrly as required. SC adults: initially 10mg every 3 hours (or more frequently during titration), adjusted according to response Slow IV, adults: IV Morphine should only be administered by staff trained to do so. Morphine should be titrated to effect to establish analgesia. THIS IS NOT A MAINTENANCE ANALGESIA- if repeated doses are required alternative routes should be considered (Oral, SC, PCA, Continuous Infusion) Hepatic impairment: opioids may precipitate coma in patients with hepatic dysfunction and should be avoided or the dose reduced. Renal impairment: analgesic effect prolonged and increased in patients with renal impairment, there is increased cerebral sensitivity when opioids are used, doses should be reduced or avoided. For complete information on any medicine please refer to the current BNF Alternative Opioids: Oxycodone (1st line over the age of 70yrs) Oxycodone is a semi-synthetic full opioid agonist with a high absolute bioavailability of up to 87% following oral administration compared to morphine, at approximately 30%. Patients having oral morphine before oxycodone therapy should have their daily dose based on the following ratio 10mg of oxycodone is equivalent to 20mg of oral morphine. In elderly patients compared with younger patients, the clearance of oxycodone is only slightly reduced.



OXYCODONE

INDICATION moderate to severe pain in patients with cancer and post-operative pain

CAUTIONS see cautions for codeine; also toxic psychosis; pancreatitis. Sunset yellow, a constituent of the 5mg capsule, can cause allergic type reactions such as asthma. This is more common in people who are allergic to aspirin.

CONTRA-INDICATIONS see contra-indications for codeine; also acute abdomen; delayed gastric emptying; chronic constipation; cor pulmonale; acute porphyria

ROUTE Oral: tablets (MR), capsules (IR), oral solution (IR) Injection: SC, IV injection or infusion

DOSE: Oral, adults: 2.5-5mg Post-Operative Regimen to establish analgesia (EPMAR) 1hry for 3 doses then 3hrly as required. Slow IV, adults: IV Oxycodone should only be administered by staff trained to do so. Oxycodone should be titrated to effect to establish analgesia. THIS IS NOT A MAINTENANCE ANALGESIA- if repeated doses are required alternative routes should be considered (Oral, SC, Continuous Infusion) SC, adults: initially 5mg every 3 hours (or more frequently during titration), adjusted according to response

For complete information on any medicine please refer to the current BNF

Suggested equivalent analgesic doses of opioid analgesia: Morphine Sulphate 10 mg IV is equivalent to 20 mg oral Morphine Morphine Sulphate 10 mg IV is equivalent to 10 mg oral Oxycodone Morphine Sulphate 10 mg IV is equivalent to 10 mg IV Oxycodone Morphine Sulphate 10 mg IV is equivalent to 100 micrograms IV Fentanyl Alternative Opioids: Fentanyl Fentanyl citrate is well established as an intravenous potent µ-opioid against for perioperative use, its low histamine release making it suitable for cardiovascular disease and patients with atopy. Fentanyl is a highly lipid soluble analgesic with a rapid onset of analgesia and a short duration of action. It is approximately 100-fold more potent than morphine as an analgesic. Fentanyl is most commonly used as a peri-operative analgesic used IV and in PCA for post operative and trauma pain management (this is an unlicensed use). Fentanyl is available as a lozenge- for acute pain this is on formulary for the management of procedural pain only http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/mm1205/ Fentanyl is also available in a transdermal form (Fentanyl Patch) for the management of chronic intractable / cancer pain where opioid requirements are stable.

http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/mm1205/




FENTANYL- Acute Pain Management INDICATION Moderate to severe post-operative pain CAUTIONS see cautions for codeine; also diabetes mellitus, impaired consciousness, cerebral tumour CONTRAINDICATIONS see contra-indications for codeine ROUTE Injection: Slow IV injection or infusion or PCA http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/twcg1613/ , epidural injection or infusion http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/twcg1713/ DOSE: Oral, adults: Refer to the Fentanyl Lozenge policy http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/mm1205/ Slow IV, adults: IV Fentanyl should only be administered by staff trained to do so. Fentanyl should be titrated to effect to establish analgesia- this is usually only administered in this way in the theatre, critical care or by the pain management team following opioid titration guidelines http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/345tdc85/ IV titration IS NOT A MAINTENANCE ANALGESIA- if repeated doses are required alternative routes should be considered (PCA or Continuous Infusion) Hepatic impairment: see notes on Morphine. Renal impairment: see notes on Morphine. Less than 10% of fentanyl is excreted unchanged by the kidney and, unlike morphine, there are no known active metabolites eliminated, it is therefore potentially a safer opioid to be used in the renal impaired patient. Elderly: monitor closely for potential sensitivity or adverse effects. A reduced dose may be needed due to fentanyl prolonged half-life in this group of patients. For complete information on any medicine please refer to the current BNF Chronic intractable pain, Fentanyl Transdermal Patch, Adults

Not suitable for acute pain management or opioid naïve patients- seek pain team advice

Currently treated with a strong opioid analgesic, initial dose based on previous 24-hour opioid requirement

NB: A fentanyl patch provides continuous systemic delivery over the 72 hour administration period at a relatively constant rate. As the concentration gradient between the matrix and skin drives drug release, serum fentanyl concentration increase gradually, generally levelling off between 12 and 24 hours, and remaining relatively constant for the remainder of the 72-hour

http://intranet/policies-resources/trust-policy-documents/trust-wide-clinical/gen/twcg1613/








application period. By the second application, a steady state serum concentration is reached and is maintained during subsequent applications of a patch the same size. After a fentanyl patch is removed, serum fentanyl concentrations will gradually decline, falling about 50% in about 17 hours following a 24 hour application. Following a 72 hour application the mean half-life ranges from 20-27 hours. Transdermal: monitor patients using patches for increased side effects if fever present (increased absorption possible); avoid exposing application site to external heat Risk of fatal respiratory depression particularly in patients not previously treated with a strong opioid analgesic; manufacturer recommends only use in opioid tolerant patients NB-If admitted for surgery with Fentanyl Patch for analgesia this should be continued. Inform the pain Team as further advice on analgesia management may be required post op. Alternative Opioids: Buprenorphine Buprenorphine is a partial mu opioid agonist but has antagonist actions at kappa and delta opioid receptors. It has a slow onset of action. It is most commonly available as a patch (BuTrans or Transtec) for chronic pain management. If using patch it may take up to 24-36 hours to reach onset of action. Half-life is about 12 hourly. Inactive when taken orally due to first pass metabolism therefore required route is sublingual or via a patch. BUPRENORPHINE INDICATION moderate to severe chronic pain (not used for acute pain management) CAUTIONS see cautions for codeine; also impaired consciousness; effects only partially reversed by naloxone; monitor liver function Transdermal: monitor patients using patches for increased side effects if fever present (increased absorption possible); avoid exposing application site to external heat CONTRA-INDICATIONS see contra-indications for codeine ROUTE Transdermal: Change every 96 hour (Transtec®) or 7 day (BuTrans®) patch NB-If admitted for surgery with Buprenorphine Patch for analgesia this should be continued. Inform the pain Team as further advice on analgesia management may be required post op. For complete information on any medicine please refer to the current BNF Alternative/Additional Opioids: Tramadol Tramadol is currently non formulary. This can be continued if prescribed as a pre-admission medication. It is most commonly used second line to Codeine where the clinician wishes to avoid traditional ‘strong’ opiates



Tramadol is a weak opioid agonist which is extensively metabolised by enzyme CYP2D6 after oral administration. This enzyme is absent in 5-10% of Caucasians, the so-called “poor metabolisers”, in whom the concentrations of the pharmacologically active metabolite are reduced. Compared to morphine, tramadol does not show respiratory depression when given within the analgesic dosage interval. The effect of tramadol is considered 1/10 to 1/6 the effect of morphine. The gastrointestinal motility is not affected. Pre-admission prescriptions of tramadol should be continued unless contraindicated. TRAMADOL INDICATION moderate to severe pain CAUTIONS see cautions for codeine; impaired consciousness; excessive bronchial secretions; not suitable as a substitute in opioid-dependent patients CONTRA-INDICATIONS see contra-indications for codeine; do not use where the patient has a history of epilepsy ROUTE Oral: Capsules, oral drops Injection: Not used in SRFT DOSE: Oral, adults: 50-100mg not more often than every four hours; total of more than 400mg daily not usually required DO NOT co-prescribe Tramadol and Codeine! For complete information on any medicine please refer to the current BNF Medications not routinely used in the management of acute pain PETHIDINE Pethidine is not available as an analgesic in SRFT due to poor analgesic properties, high addictive potential and risk of toxicity and seizures due to metabolites. If patients request Pethidine an alternative opioid should be prescribed in accordance with pain assessment. Please alert the PAIN MANAGEMENT TEAM For complete information on any medicine please refer to the current BNF ENTONOX Entonox is used for the management of procedural pain only. This is not maintenance analgesia. In cases of prolonged use inform the Pain Team DIAMORPHINE Not routinely used in acute pain management.



Using Opioids in Post-Operative pain Management Where possible the oral route should be used. Alternative routes for major surgery include PCA and Epidural analgesia. Oral opioid analgesia will usually follow a period of IV titration of opioids to establish analgesia effect/ response but may be prescribed following: • IV opioid titration in recovery, • Discontinuation of PCA/ opioid infusion • Discontinuation of Epidural infusion • On receiving maximum dose of weak opioid analgesia and patient reporting severe pain. Oral opioid prescriptions should incorporate a titration period to establish analgesia when commencing or converting to oral analgesia. It is important to note that IV titration of opioids is often required in the recovery room to quickly establish blood plasma concentration/levels. Oral opioid analgesia (Morphine and Oxycodone) for post-operative or trauma pain should be prescribed in EPMAR. The regimen can be found in the post-op order sets or by typing in ‘Morphine’ or ‘Oxycodone’ (70yrs and older, those with renal impairment or allergy). Select the ‘post-operative’ order set. The first three doses can be titrated at hourly intervals as required. The prescription then automatically reduces frequency to 3hrly intervals as required. Once a patient has been commenced on an oral strong opioid, if the drug needs to be changed, e.g. from Morphine to Oxycodone the patient should not have a further period of 1 hourly dosing. The starting dose is based on patient assessment, but in fit healthy adults this is often 10-20mg of Morphine (or equivalent). Increasing on patient requirement or decreasing if the patient is frail or elderly. For patients 70yrs and older, those with renal impairment or allergy to morphine, Oxycodone should be considered. Doses up to 10 mg should be prescribed, though may need adjusting depending on individual assessment. If initial titration at hourly intervals remains ineffective (Patient continues to report severe pain and/or is unable to take a deep breath and cough effectively) advice should be sought regarding the dose/method of analgesia administered. The clinician needs to consider increasing the dose of opioid analgesia or giving an IV bolus dose (to establish effectiveness) or commencing a PCA. Staff who have completed enhanced role training can administer IV boluses. If PCA is required, oral opioid analgesia should be discontinued for the duration of the PCA infusion and recommenced as per protocol once PCA is no longer required. Sedation and respiratory depression are recognised side effects of opioid analgesia and should not be confused with overdose which is ‘an excessive and dangerous amount of a drug’ (Oxford English Dictionary). If opioid analgesia is administered as protocol and the patient is monitored as protocol then the dose is not excessive (recognised dose). Nor is it dangerous if the patient



is monitored, resuscitation equipment should be available in all clinical areas along with Naloxone for the management of opioid related side effects. Nausea and vomiting is a common side effect of anaesthesia, surgery and analgesia. The PONV guidelines should be implemented for symptomatic management. Pruritus- Symptomatic management with Chlorphenamine. Constipation – local guidelines should be followed depending upon surgical intervention. Naloxone is the reversal agent for opioid induced sedation and respiratory depression. Naloxone should be titrated as per APS guidelines. If long acting opioids have been administered an infusion of Naloxone may be required. Adverse effects of Opioid Analgesia Opioid Toxicity

The dose of opioids causing toxicity varies between individuals and depends on medical comorbidities, particularly renal or hepatic impairment, and concomitant medication therapy, including over the counter medication and illicit drug use. Clinical features of opioid toxicity

Pinpoint pupils

Sedation

Slow respiration

Visible cyanosis e.g. lips, ears, nose

Myoclonic jerks

Snoring when asleep

Agitation

Confusion

Vivid dreams, nightmares or hallucinations

More severe cases: hypotension, coma convulsions



NB : Complete AIR form when Naloxone is administered.



Opioid withdrawal occurs when an opioid is stopped suddenly, the dose tapered too rapidly, or when an opioid antagonist (i.e. Naloxone) is given. Signs of opioid withdrawal (adapted from the BPS):

Sweating

Mydriasis

Piloerection

Yawning

Abdominal cramps/vomiting/diarrhoea

Bone and muscle pain

Increase in usual pain

Restlessness

Anxiety

Rhinorrhoea

Lacrimation

Tremor

Significant withdrawal symptoms may be experienced after discontinuation of tramadol, even after short periods of dosing. If opioid withdrawal is suspected, use the Clinical Opiate Withdrawal Scale (COWS) to assess severity; (Appendix 3) This form is to be completed on EPR.

Opioid induced Hyperalgesia, Tolerance and dependency

Opioid induced Hyperalgesia, a state of abnormal pain sensitivity, has been demonstrated

following prolonged use of opioids. Clinically presenting with increased pain, this may be

qualitatively distinct from pain related to disease progression or to breakthrough pain resulting

from development of opioid tolerance, and is managed by opioid dose reduction or changing to

an alternative opioid preparation.

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a

diminution of one or more of the drug’s effects over time, developing within a few days to

opioids. Clinical experience suggests that immediate release preparations are more commonly

associated with tolerance and problem drug use.

Physical dependence refers to a state in which drug withdrawal causes adverse physiological

effect(s) and occurs to some degree after morphine has been given for a few days.



6. Roles and responsibilities

Consultant Pain Nurse. • Accountable to the Executive Nurse Director & Trust Board for review and maintenance of this policy standard. Pain Management Team. are responsible for

checking that their activities comply with the guidance in this policy.

for training and assessing link nurses and other identified staff in the use of this policy.

monitoring and recording practice to ensure all SRFT staff comply with this policy.

reviewing this protocol regularly and making timely updates

Link nurses and other identified staff with enhanced role. • are responsible for complying with the protocol and reporting to the pain management team. Modern Matrons, Ward Managers are responsible for ensuring compliance with policy from all

staff in surgical clinical areas.

7. Monitoring document effectiveness

• The policy will be reviewed by the Pain Team on an on-going basis and will undergo full review a minimum of every two years. • Datix incidents will be monitored to assess compliance with policy. RCA will be completed and any gaps in knowledge will be addressed locally

8. Abbreviations and definitions

Awake and Responsive, Responds to Verbal, Responds to Painful Stimulus, Unresponsive, (AVPU) Adverse Incident Report (AIR) Intravenous (IV) Subcutaneous (SC) Electronic Prescribing and Medicines Administration Record (EPMAR) Post Op Nausea and Vomiting (PONV) Patient Controlled Analgesia (PCA) Salford Royal NHS Foundation Trust (SRFT) Chronic Obstructive Pulmonary Disease (COPD) Modified Release (MR) Immediate Release (IR)



9. References and Supporting Documents

9.1 References

Acute Pain Management Scientific Evidence 3rd Ed (2010). Australian and New Zealand College Of Anaesthetics and Faculty of Pain Medicine. Aderjan RE, Skopp G (1998) Formation and clearance of active metabolites of Opiates in Humans (Proceedings Of The Fifth International Congress Of Therapeutic Drug Monitoring And Clinical Toxicology) Therapeutic Drug Monitoring, Lippincott Williams and Wilkins Inc. Vol 20 (5) 561-569. Davis MP Vargan J, Dickerson, D, Wals D, LeGrand SB, Lagman R (2003) Normal release and controlled release Oxycodone: pharmacokinetics, Pharmacodynamics and controversy Support Cancer Care 11:84-92. McQuay H (1999) Opioids in pain management. Lancet Vol 353 June 26 1999. Oxford English Dictionary NPSA- RAPID RESPONSE REPORT: NPSA/2008/RRR05 Reducing Dosing Errors with Opioid Medicines July 2008

9.2 Related SRFT/PAT documents • Opioid Loading Dose (PCA IV Titration) Protocol for administration of 345TD(C) 85.

• Complex post-operative acute pain management Protocol for theatres and critical care settings

TWCG01 (14).

• Fentanyl Lozenge MM12(05)



10. Document Control Information

Nominated Lead author:

Fionn Murison Highly Specialised Pain Nurse

Lead author contact details:

0161 206 4248 [email protected]

Lead Author’s Manager:

Name Susan Barnes Role Consultant Nurse Pain Management

Applies to: Please indicate which Care Organisation(s) this document applies to:

Salford CO

Document developed in consultation with :

Endorsed by:

Name of Lead Clinician/Manager or Committee Chair

Position of Endorser or Name of Endorsing Committee

Date

Justin Turner Clinical Lead, Pain 27.10.14

Alison Dwyer, Consultant Nurse, Pain 27.10.14

Dr Richard Makin, Acute Pain Lead 27.10.14

Dr J McDonald MMG Committee Chair 27.10.14

Dr Paul Chadwick MMG Committee chair 21.11.16

Dr J McDonald MMG Committee chair 19.11.18

Keywords/ phrases:

Opioids, Titration, Monitoring, Side effects, Naloxone, Morphine Sulphate, Oxycodone

Communication plan:

The policy will be available on synapse under acute pain, critical care and anaesthesia. The updated policy will be disseminated via e-mail to anaesthetists, ward managers and link nurses. The content of the policy will be included in all pain management teaching and training events. This policy reflects current practice within SRFT

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: Medicines Management Group

Dr John McDonald

19/11/2018

How approved: Chair’s actions Formal Committee decision X



11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

No

1b) Have any amendments been made as a result? If yes, specify what.

No

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect age groups in different ways?)

X

Sex (e.g. is gender neutral language used in the way the policy or information leaflet is written?)

X

Race (e.g. any specific needs identified for certain groups such as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions; dietary needs that may conflict with medication offered.)

X

Sexual orientation (e.g. is inclusive language used? Are there different access/prevalence rates?)

X

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or breastfeeding women?)

X

Marital status/civil partnership (e.g. would there be any difference because the individual is/is not married/in a civil partnership?)

X

Gender Reassignment (e.g. are there particular tests related to gender? Is confidentiality of the patient or staff member maintained?)

X

Human Rights (e.g. does it uphold the principles of Fairness, Respect, Equality, Dignity and Autonomy?)

X

Carers (e.g. is sufficient notice built in so can take time off work to attend appointment?)

Not applicable

Socio/economic (e.g. would there be any requirement or expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical

X



disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

X

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? Caution with use in pregnancy. Pain Team should be contacted on 07623623107 for advice and support. Patients with poor command of English will need consent and education with the aid of Trust interpretors 4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? N/A (what action has been taken or will be taken, who is responsible for taking a future action, and when it will be completed by – may include adjustment to wording of policy or leaflet)

Will this policy require a full impact assessment? No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or if you believe there is a potential for it to affect a group differently and do not know how to mitigate against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Fionn Murison Date: 05/11/18 Sign off from Equality Champion: Simon H Gray Date: 15/11/18

mailto:[email protected]



12. Appendices

Appendix 1 Pain Assessment Tools

Pain the fifth vital sign!

1. Verbal Descriptor Scale- this is a self-report tool

Ask the patient ‘do you have any pain’?

Assess at rest and on Movement

Ask if pain is mild moderate or severe

Score as below

2. Abbey Pain Assessment

This is for patients who are unable to reliably self-report pain

No Pain 0

Mild Pain 1

Moderate Pain 2

Severe pain 3



Appendix 2



Appendix 3

SEVERE PAIN

STEP 3

STRONG OPIOIDS FOR SEVERE PAIN (e.g. Morphine Sulphate 1.R. Oramorph, Oxycodone I.R. See protocol) PARACETAMOL 1gram regular prescription (Max 4 grams / 24 hrs) ASSESS PATIENT AND CONSIDER NSAIDS

(Non-steroidal anti-inflammatory drugs) CONSIDER OTHER ADJUVANTS

MODERATE PAIN

STEP 2

WEAK OPIOID FOR MODERATE PAIN (e.g. Codeine Phosphate) PARACETAMOL 1gram regular prescription (Max 4 grams / 24 hrs) ASSESS PATIENT AND CONSIDER NSAIDS

(Non steroidal anti-inflammatory drugs) CONSIDER OTHER ADJUVANTS

MILD PAIN

STEP 1

NON-OPIOID PARACETAMOL 1gram regular prescription (Max 4 grams / 24 hrs) ASSESS PATIENT AND CONSIDER NSAIDS

(Non steroidal anti-inflammatory drugs) CONSIDER OTHER ADJUVANTS

SALFORD ROYAL NHS FOUNDATION TRUST Analgesic Ladder (Adapted from World Health Organisation (WHO) Analgesic Ladder 1986)

PA

IN P

ER

SIS

TIN

G

MO

VE

UP

ON

E S

TE

P A

T A

TIM

E

SIG

NS

OF

TO

XIC

ITY

OR

SE

VE

RE

SID

E E

FF

EC

TS

R

ED

UC

E T

HE

DO

SE

OR

MO

VE

DO

WN

A S

TE

P



Clinical Opiate Withdrawal Scale (COWS) Complete on line form on EPR

Patient’s Name:___________________________ Date: ______________ Medication : ________________________________________________________________________ Last used : _________________________________________________________________________

Resting Pulse Rate: (record beats per minute)

Measured after patient is sitting or lying for one

minute

0 pulse rate 80 or below

1 pulse rate 81-100

2 pulse rate 101-120

4 pulse rate greater than 120

Sweating: over past ½ hour not accounted for by

room temperature or patient activity.

0 no report of chills or flushing

1 subjective report of chills or flushing

2 flushed or observable moistness on face

3 beads of sweat on brow or face

4 sweat streaming off face

Restlessness Observation during assessment

0 able to sit still

1 reports difficulty sitting still, but is able to do so

3 frequent shifting or extraneous movements of

legs/arms

5 Unable to sit still for more than a few seconds

Pupil size

0 pupils pinned or normal size for room light

1 pupils possibly larger than normal for room light

2 pupils moderately dilated

5 pupils so dilated that only the rim of the iris is

Visible

Bone or Joint aches If patient was having pain

previously, only the additional component attributed

to opiates withdrawal is scored

0 not present

1 mild diffuse discomfort

2 patient reports severe diffuse aching of joints/

muscles

4 patient is rubbing joints or muscles and is unable

to sit still because of discomfort

Runny nose or tearing Not accounted for by cold

symptoms or allergies

0 not present

1 nasal stuffiness or unusually moist eyes

2 nose running or tearing

4 nose constantly running or tears streaming down

cheeks

GI Upset: over last ½ hour

0 no GI symptoms

1 stomach cramps

2 nausea or loose stool

3 vomiting or diarrhea

5 Multiple episodes of diarrhea or vomiting



Tremor observation of outstretched hands

0 No tremor

1 tremor can be felt, but not observed

2 slight tremor observable

4 gross tremor or muscle twitching

Yawning Observation during assessment

0 no yawning

1 yawning once or twice during assessment

2 yawning three or more times during assessment

4 yawning several times/minute

Anxiety or Irritability

0 none

1 patient reports increasing irritability or anxiousness

2 patient obviously irritable anxious

4 patient so irritable or anxious that participation in the assessment is difficult

Gooseflesh skin

0 skin is smooth

3 piloerrection of skin can be felt or hairs standing

up on arms

5 prominent piloerrection

Total scores