opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative...

Opioids in palliative care:safe and effective prescribing of strong opioids

for pain in palliative care of adults

Support for education and learning

Training slide set for primary and secondary care

June 2012

NICE clinical guideline 140

What this presentation covers

Part 1

•Background/ scope

•Aims and learning objectives

Part 2

•Clinical case scenarios

Part 3

•Discussion and evaluation

Part One

Background

• Pain which results from advanced disease remains under-treated

• Strong opioids, especially morphine, are the principal treatments for pain related to advanced and progressive disease

• Prescribing advice has been varied and sometimes conflicting

Scope

This guideline covers:-

• first-line treatment with strong opioids for patients

• the following drugs: buprenorphine, diamorphine, fentanyl, morphine and oxycodone

• the clinical pathway needed to improve pain management and patient safety when prescribing strong opioids as a first-line treatment

Aims

The aims of the workshop are to:

•promote awareness and understanding of NICE’s recommendations

•increase knowledge of how to apply them as part of routine practice, whilst taking account of individualised care

•practise identifying the risk factors and indicators for use of opioids

Learning objectives 1

By the end of the session, participants should have improved knowledge on:

•the verbal and written information on strong opioid treatment that should be given to patients and carers

•patient side effects such as constipation, nausea and drowsiness

•appropriate first line treatment for patients

Learning objectives 2

• actions to take for patients who have moderate renal or hepatic impairment or are unable to take oral opioids

• ‘starting doses’ of strong opioids for patients

• how to effectively titrate opioid doses

• how to prescribe effective breakthrough medication

Pre-workshop quiz

?Please complete the pre-workshop

quiz

Part 2

Clinical case scenarios for primary care

List selected scenarios……..

Scenario 1: Begum

Presentation

Begum Akhtar is a 38 year old woman who was diagnosed with liver metastases from colorectal cancer 6 weeks ago. She has pain in her right upper quadrant which she describes as intense 6/10 on a 10 point visual analogue scale

She started taking strong opioids 4 weeks ago. She felt drowsy when she started her morphine but her pain was reduced usefully. One week after starting her morphine the intensity of her pain increased and her dose was adjusted

Scenario 1: Begum

Medical history

Begum Akhtar has been well since the onset of her symptoms. Her only surgery is the hemi-colectomy 1 year previously

Begum Akhtar is married and has two children of school age

Scenario 1: Begum

On examination

Begum Akhtar is taking morphine sustained-release 30 mg twice daily. She has a supply of morphine liquid but is not using this as a dose of 10 mg makes her feel drowsy. She has constant pain in her right upper quadrant and is having difficulty sleeping. She has not reported feeling constipated

She has tried taking other adjuvant medications such as non-steroidal anti-inflammatory drugs (NSAIDs), regular paracetamol and a small dose of dexamethasone, with no effect

Scenario 1: Begum

Next steps for management

1.1 Question

What medication advice do you give to Begum Akhtar?

Scenario 1: Begum

1.1 Answer

Advise Begum Akhtar to try increasing her sustained-release morphine to 40 mg twice daily for 1 week and then increase to 50 mg twice daily. She should try taking a dose of morphine liquid 10 mg at night to help her sleep

At each dose change, discuss expected side effects

Explain that several dose adjustments might be needed to achieve useful pain relief

Scenario 1: Begum


Begum Akhtar comes back to the surgery 2 weeks later. Sustained-release morphine 40 mg twice daily has improved her pain to 5/10 in the day. She is struggling to manage her daytime pain. She is sleeping better with her night-time dose of immediate-release morphine

1.2 Question

What do you advise about Begum Akhtar’s medication?

Scenario 1: Begum

1.2 Answer

Advise Begum Akhtar that her drowsiness may reduce in a few days. If she still feels drowsy she should reduce her dose back to 40 mg twice daily

Arrange to talk to her again within 5 days for a medication review

Scenario 1: Begum


Begum Akhtar still feels sleepy after 1 week on morphine 50 mg twice daily. She has dropped the dose to 40 mg twice daily and her pain has worsened

1.3 Question

What is the next best step?

Scenario 1: Begum

1.3 Answer

Begum Akhtar’s pain is responsive to opioids but she is getting sedative side effects. A different opioid should be tried – for example, buprenorphine, diamorphine or oxycodone. Dose conversion tables are a rough guide only

Always explain to the patient that they may get side effects from the new drug

Scenario 1: Begum

1.4 Question

What should you advise Begum Akhtar about driving?

Scenario 1: Begum

1.4 Answer

Begum Akhtar should not drive if she feels drowsy or has poor concentration. Opioid symptoms may vary at different times of day. Lack of sleep and pain can also interfere with driving. Opioids may be more sedating if patients are given other medications in addition

Advise Begum Akhtar that she must consider whether she feels fit on every occasion that she wants to drive

Scenario 1: Begum


Begum Akhtar is taking a new opioid preparation. She feels drowsy when she takes a dose that controls her pain

1.5 Question

What do you suggest?

Scenario 1: Begum

1.5 Answer

You should seek specialist advice

Scenario 2: Helena

Presentation

Helena presents at her GP surgery with worsening abdominal pain. The pain is mainly localised to the right upper quadrant of her abdomen and can vary in nature, but for the past 2 weeks has been present most of the time

It has prevented her from sleeping for the past 3 nights, and she feels exhausted

Scenario 2: Helena

Past medical history

Helena is 68 and retired. A year ago she was found to have a large abdominal mass, which was found to be an ovarian carcinoma

It was found to have spread throughout her peritoneal cavity at presentation and therefore a palliative treatment regimen was started. Despite chemoradiotherapy, she developed widespread intraperitoneal lymph node involvement

Continues on next slide

Scenario 2: Helena

Past medical history: continued

A recent CT-scan showed four separate small masses in her liver, likely to be metastases

Recent blood tests including liver and renal function have been normal

She has been taking two co-codamol 30/500 tablets four times a day, but they only had a limited effect. She has tried NSAIDs but cannot tolerate them as they give her severe epigastric discomfort

Scenario 2: Helena

On examination

She is not jaundiced but does look very tired. Her abdomen is distended and on palpating her liver the GP notes that it is enlarged

The area around her right upper quadrant is very tender, but there is no guarding or rebound tenderness

Scenario 2: Helena


2.1 Question

She has been taking two co-codamol 30/500 tablets four times daily

What would you discuss with her about next steps specifically regarding pain management options?

Scenario 2: Helena

2.1 Answer

It would appear that she needs stronger pain relief, and she should be offered regular oral morphine, either as an immediate-release or as a sustained-release preparation

She should also be offered rescue doses of oral immediate-release morphine for breakthrough pain. You should also investigate the possibility of constipation

Scenario 2: Helena

2.2 Question

What dose of morphine would you start her on?

Scenario 2: Helena

2.2 Answer

She has been on two tablets of co-codamol 30/500 four times daily. This equates to an equivalent daily dose of oral morphine of approximately 24 mg over a 24‑hour period

She could be started on oral immediate-release morphine 5 mg every 4 hours (amounting to a total daily dose of 30 mg of oral morphine)


Scenario 2: Helena

2.2 Answer: continued

Alternatively she could be started on oral sustained-release morphine 15 mg every 12 hours

It is important that she also understands that if this dose regimen is insufficient and she has breakthrough pain, she can take additional oral immediate-release morphine 5 mg as required

Scenario 2: Helena

2.3 Question

When you mention the word morphine, she flinches and says “Oh no!” What would you discuss with her?

Scenario 2: Helena

2.3 Answer

Establish what her concerns are and what her ideas about morphine and strong opioids are. It is likely that she has worries and preconceptions about morphine; for instance, she may think morphine signifies the imminent end of her life or that it will kill her. She may also be fearful of addiction

You should offer her a follow-up consultation to discuss these matters further and to review how her pain control is going

Scenario 2: Helena

2.4 Question

She has a lot of questions about morphine, including how often to take the medication and when to take breakthrough doses

She also wants to know what side effects to look out for. What would you do to provide her with more information?

Scenario 2: Helena

2.4 Answer

She may need help in drawing up a timetable showing the times when she should take her medication

It is also important to mention potential side effects like constipation, nausea, vomiting, drowsiness and hallucinations

You may wish to provide her with some additional written information


Scenario 2: Helena 2.4 Answer: continued

If there is access to a specialist community palliative care team, this may further help in following up medication queries and monitoring response to treatment

It is also important to discuss whom she can contact out of hours, if her pain should get worse or she develops side effects. When you mention possible interference with driving Helena admits that she finds it too painful and relies on her partner now to ‘chauffeur’ her around

Scenario 2: Helena

2.5 Question

Helena returns 2 days later and says that the pain control is working reasonably well, but that she is finding taking regular oral immediate-release morphine every 4 hours cumbersome

She says she has read the leaflets and would like to consider a sustained-release preparation. What would you do?

Scenario 2: Helena

2.5 Answer

Establish how much immediate-release morphine she has been taking regularly and how much she has been taking in addition for breakthrough pain

Offer an oral sustained-release preparation of morphine every 12 hours that is equivalent in dose to her current oral immediate release preparation and advise her she can take additional oral immediate-release morphine for breakthrough pain as required


Scenario 2: Helena


For instance, if she has been taking 5mg immediate-release oral morphine every 4 hours (that is, six times a day equalling 30 mg over 24 hours), offer oral sustained-release morphine 15 mg twice daily (every 12 hours)

In addition, she should be told that she can still take oral immediate-release morphine for breakthrough pain

Scenario 2: Helena

2.6 Question

She returns several weeks later. Her sustained-release morphine has been titrated up to 30 mg twice daily and she is taking four additional doses of immediate-release morphine 10 mg as rescue doses for her breakthrough pain

Despite this, she remains in pain. She has also found that she is seeing shapes and figures appear and disappear. What action should you take?

Scenario 2: Helena 2.6 Answer

There are several issues here, so seek advice from your local specialist palliative care team; her pain is not being controlled and she is getting side effects

If her pain were well controlled, an opioid dose reduction may have been indicated, but this is not the case. Establish whether she thinks the oral morphine is actually reducing her pain when she takes it (that is, is this still an opioid-responsive pain?)

Scenario 3: Vera

Presentation

Vera is a 70 year old woman with bone and liver metastases from a breast cancer primary


None, normal renal function, mild hepatic impairment

Scenario 3: Vera

On examination

Right upper quadrant pain, which is constant. Vera is currently taking 30/500 mg co‑codamol four times a day


3.1 Question

What strong opioid should Vera be prescribed and at what dose?

Scenario 3: Vera

3.1 Answer

There is no renal impairment and only mild hepatic impairment

Vera should be offered (unless contraindicated) regular oral sustained-release or immediate-release morphine (depending on her preference) with rescue doses of oral immediate‑ release morphine for breakthrough pain


Scenario 3: Vera3.1 Answer: continued

The typical daily starting dose should be 10 -15 mg sustained-release oral morphine 12 hourly plus rescue doses of 5 mg immediate-release oral morphine for breakthrough pain

or

2.5 - 5 mg immediate-release oral morphine 4-hourly plus rescue doses of 5 mg immediate-release oral morphine for breakthrough pain

Scenario 3: Vera


Following discussion, Vera was started on 10 mg sustained-release oral morphine 12-hourly and 5 mg immediate-release oral morphine for breakthrough pain

3.2 Question

What information should you provide to Vera about the management of side effects at this point of initiating opioid therapy?

Scenario 3: Vera

3.2 Answer

Discuss the risk of constipation with Vera, and prescribe laxatives when initiating strong opioids

Advise her that nausea may occur when starting opioid treatment, but it is likely to be transient

Also advise Vera that mild drowsiness or impaired concentration may occur when starting opioid treatment, but that it is often transient

Scenario 3: Vera

3.3 Question

What drug group should be prescribed for Vera at the time of initiating opioid therapy?

Scenario 3: Vera3.3 Answer

Laxatives


Vera lives alone and is anxious about using morphine, believing that this signifies the end of her life. She is also fearful that her pain will continue

3.4 Question

How should you manage Vera’s concerns?

Scenario 3: Vera

3.4 Answer

Advise Vera that morphine is used when a strong pain medication is needed, many people may not recall that they have taken it in this kind of situation

Using it does not mean that her condition has changed, just that she needs strong pain medication


Scenario 3: Vera


Provide written and verbal information about strong opioid treatment for her and her family/carers

Plan the next review with Vera and provide contact information before her planned review of who to contact if her pain is not improved or if she experiences persistent side effects

Scenario 3: Vera


Vera returns to your surgery for her planned review 1 week later

In addition to taking the 10 mg sustained-release oral morphine 12 hourly, she has needed an average of two additional doses of 5 mg immediate-release oral morphine every 24 hours to adequately control her pain

Her bowels are working regularly with regular laxatives and she hasn’t experienced any side effects

Scenario 3: Vera

3.5 Question

What would your next steps be in opioid management?

Scenario 3: Vera

3.5 Answer

Increase sustained-release oral morphine from 10 mg to 15 mg 12 hourly and advise Vera to continue to take 5 mg immediate-release morphine for breakthrough pain

Scenario 4: Bill

Presentation

Bill is a 58 year old man with end-stage motor neurone disease


None of note

Scenario 4: Bill

On examination

Bill has been taking strong opioid treatment for 3 weeks. His sustained-release oral morphine was increased 1 week ago from 20 mg 12 hourly to 30 mg 12 hourly

Bill’s general muscular pain all over his body has improved. Bill takes 5 mg immediate-release oral morphine for breakthrough pain. Bill’s continued expressed wishes are to remain and die at home


Scenario 4: BillOn examination: continued

You receive a message at the surgery to inform you that Bill called 999 last night because of all over pain in his body. Bill was taken to the accident and emergency department at your local hospital and discharged the same night

You review Bill at home and he is comfortable and his pain is controlled. There are no other factors contributing to this pain. Before he called 999 Bill took one dose of 5 mg immediate-release oral morphine, which only partly reduced his experience of the pain

Scenario 4: Bill


4.1 Question

What should your management approach be?

Scenario 4: Bill

4.1 Answer

Increase the immediate-release oral morphine dose to 10 mg when needed

4.2 Question

What other healthcare professionals might you involve in Bill’s care?

Scenario 4: Bill

4.2 Answer

If not already done, inform out of hours services of Bill’s diagnosis and current plan for analgesic management

With Bill’s consent, ensure his end of life wishes and analgesic management plan is entered on the local end of life register (if available) to ensure continuity of care by all professionals

Consider referral to community nursing and community palliative care services

Scenario 4: Bill

4.3 Question

What information should you give to Bill about future management of breakthrough pain at night?

Scenario 4: Bill4.3 Answer

Inform Bill to use 10 mg immediate-release oral morphine as first line

If the above has no impact after 1 hour, repeat the rescue dose. If after a further 45 minutes there is still pain, call the local out of hours service provider, not an ambulance

Ensure Bill has the out of hours contact numbers available and accessible. If referral has been made to community palliative care, provide their advice line number if available

Clinical case scenarios for secondary care

List selected scenarios……..

Scenario 5: Syed

Presentation

Syed is a 42 year old man who has recently been diagnosed with a metastatic right renal cell carcinoma

He started strong opioids 5 days ago and has been admitted with a 5 day history of nausea and 3 day history of feeling bloated


None of note

Scenario 5: Syed

On examination

Syed is pale, tender over the lumbar spine area and appears dehydrated. He has active bowel sounds


5.1 Question

What medication should you prescribe for Syed?

Scenario 5: Syed

5.1 Answer

Syed should be prescribed an anti-emetic

When starting strong opioids there is a possibility that the patient may become nauseated but this is usually transient

Because the nausea has persisted for 5 days the introduction of a regular anti-emetic should now be considered

Scenario 5: Syed


Because of starting opioid treatment Syed has also been experiencing problems with his bowels. You assess his bowel action

5.2 Question

Syed is constipated and feeling very uncomfortable. What drugs should he be prescribed?

Scenario 5: Syed

5.2 Answer

Syed has been prescribed laxative treatment but has not been taking this as he has felt nauseated and bloated

Syed should be encouraged to take laxatives on a regular basis

Syed should be informed that the treatment to alleviate the constipation may take some time to work

Scenario 5: Syed


You ask Syed if he has any abdominal pain and establish what his normal bowel pattern was before starting strong opioids

You ask him if there is any change in micturition, because urinary retention can be a complication of constipation

You advise Syed to drink as much clear fluids as he can tolerate

Scenario 5: Syed

5.3 Question

What other steps will be important to ensure Syed feels supported in making these changes?

Scenario 5: Syed

5.3 Answer

For anyone starting on strong opioids it is important to discuss the potential side effects with them

It is also vital that they are given written and verbal information and details of who to contact for further advice

Scenario 6: Maria

Presentation

Maria is a 44 year old woman with metastatic breast cancer and spinal cord compression. She spends most of her time in bed


Asthma

Scenario 6: Maria

On examination

Maria reports that while being washed in bed she has particular issues with pain. Maria currently takes oral sustained-release morphine sulphate 10 mg 12 hourly

On assessing Maria’s pain it is clear that she does not just have pain when being washed in bed but at other times as well

Scenario 6: Maria

Next steps for diagnosis

6.1 Question

You suspect Maria may have breakthrough pain. What would your next step be?

Scenario 6: Maria

6.1 Answer

This indicates that her background pain is not well controlled. On discussion you discover that when Maria takes immediate-release morphine as rescue medication her pain improves

Therefore Maria’s sustained-release preparation should be increased to control her background pain. The dose should be adjusted until there is an acceptable balance between pain control and side effects

Scenario 6: Maria

6.2 Answer

Maria should be encouraged to have a rescue dose of 5mg immediate-release morphine before having her wash in bed

It is important that healthcare professionals consider Maria's pain needs with her, in enough time before carrying out interventions such as washing which Maria finds painful


Scenario 6: Maria


Patients who are on background oral morphine and who have breakthrough pain should be offered a morphine immediate-release preparation as first-line treatment for breakthrough pain

If the pain remains inadequately controlled then specialist advice should be sought

Scenario 7: Costas

Presentation

Costas is a 48 year old man, married with a son aged 13 years. He has been a roofer since leaving school at 16

He was diagnosed with oesophageal cancer 10 months ago. He is now undertaking a course of chemotherapy as an outpatient with the goal of shrinking the tumour before surgery

Scenario 7: Costas


Smoker of 20 years, pleural plaques diagnosed 10 years ago, extraction of two wisdom teeth at 18 years, osteoarthritis in his knees and ankles

Scenario 7: Costas

On examination

Costas is a little short of breath. His oxygen saturations are maintained at 92% on air. He is in a lot of pain and is very anxious

Costas takes regular anti-inflammatories and gastro-protection, and has been titrated to 45 mg of oral sustained-release morphine twice daily, with rescue doses of 10 mg oral immediate-release morphine for breakthrough pain

Scenario 7: Costas


7.1 Question

He is still in pain, what would you prescribe for him?

Scenario 7: Costas

7.1 Answer

Increase sustained-release oral morphine from 45mg to 60mg 12 hourly and advise Costas to continue to take 20 mg immediate-release morphine for breakthrough pain

Ask him to keep a pain diary and a record of breakthrough doses to help to optimise the regular dose

Scenario 7: Costas


Costas returns at his next outpatient appointment stating that he is now finding it difficult to swallow (dysphagia) so he is finding it difficult to take his oral medication

7.2 Question

What would your next step in his opioid management strategy be?

Scenario 7: Costas

7.2 Answer

Because Costas is now finding it hard to swallow but the level of medication is controlling his pain, through discussion with Costas you should suggest he has the equivalent medication via a transdermal patch

Costas could have been prescribed Morphine Sulphate Tablet (MST) granules if he had preferred

Scenario 7: Costas


Costas now reports that his pain has become very erratic and is not being well controlled

7.3 Question

How would you respond to his pain management needs?

Scenario 7: Costas

7.3 Answer

You agree with Costas that because he is finding swallowing oral medication difficult and his pain is no longer controlled

Subcutaneous medication should be prescribed and that you will contact pain specialist colleagues for advice on managing his pain

Scenario 8: Arthur

Presentation

Arthur is a 68 year old man who has carcinoma of his prostate with bone metastases

He is in hospital after being noted to be very unwell in clinic, when he was due to have a bisphosphonate infusion for his bone metastases

He is admitted acutely and has subsequently been diagnosed with bronchopneumonia, and is now receiving intravenous antibiotics for this

Scenario 8: Arthur


Arthur has a past history of hypertension, angina and osteoarthritis

On examination

He is still markedly dyspnoeic and is receiving supplementary oxygen via a mask. He has known bone metastases and is especially tender over his right lower rib-cage, an area where he had radiotherapy to 3 weeks previously

Scenario 8: Arthur


He is on regular oral paracetamol 1g four times daily and oral ibuprofen 400 mg four times daily

Despite this, he is complaining of a lot of pain in his ribs about three or four times a day, which can come on quite suddenly and lasts for hours

At home he was taking oral immediate-release morphine 10 mg about twice a day, which did help the pain, but made him quite sleepy


Scenario 8: Arthur

Next steps for management: continued

He has no renal or hepatic complications. You notice on the hospital drug chart that the ‘as required medicines’ section has been left blank by the admitting medical officer

8.1 Question

What would you prescribe initially?

Scenario 8: Arthur

8.1 Answer

The bisphosphonate that Arthur is receiving is also analgesic. Despite this, his pain is still uncontrolled. Arthur has considerable pain so needs regular opioid analgesia as well as some rescue doses of oral immediate-release morphine for breakthrough pain

The hospital doctor may wish to offer him a regimen of immediate-release morphine 5 mg orally every 4 hours (six times daily)

Scenario 8: Arthur


Alternatively, he could be offered 10 or 15 mg of oral sustained-release morphine twice daily

Whichever option is chosen, he should also be prescribed rescue doses of oral immediate-release morphine 5 mg in the ‘as required medicines’ section of his hospital drug chart

He should be able to request these for breakthrough pain, or be offered them when he appears in discomfort

Scenario 8: Arthur

8.2 Question

What else would you prescribe alongside the morphine?

Scenario 8: Arthur

8.2 Answer

You would explain that regular opioids are very likely to cause constipation, and that most people who start them will get this side effect

Offer regular laxatives

You should also mention that some people get nausea and/or vomiting when they start taking opioids, and that this is usually transient. You could consider prescribing some ‘as required’ anti-emetic medication on his hospital medication chart

Scenario 8: Arthur

8.3 Question

Both Arthur and his wife, who has just arrived on the ward, want to know how the morphine works, at what times it is given and what other side effects it has

What do you discuss?

Scenario 8: Arthur

8.3 Answer

It is important that they are fully informed about why he has been prescribed opioids and what side effects he might experience

Provide verbal and written information on strong opioid treatment to patients and carers


Scenario 8: Arthur


•when and why strong opioids are used to treat pain• how effective they are likely to be•taking strong opioids for background and breakthrough pain, addressing:

- how, when and how often to take strong opioids- how long pain relief should last

• side effects and signs of toxicity• safe storage• follow-up and further prescribing•information on who to contact out of hours

Scenario 8: Arthur


Arthur is now on oral sustained-release morphine tablets 15 mg twice daily. His pain is better 3 days later but he still gets some pain about four times a day in the area where he has known bone metastases (his ribcage)

He finds the rescue doses of oral immediate-release morphine 5 mg helpful

Scenario 8: Arthur

8.4 Question

What would your next step in his opioid management strategy be?

Scenario 8: Arthur

8.4 Answer

Initially, carefully re-establish whether this is his ongoing pain (bone metastases) or whether there is a new problem such as a rib fracture or another underlying disease process

For his pain management, offer him a higher dose of oral sustained-release morphine in line with the amount of breakthrough medication he has needed


Scenario 8: Arthur


For instance, if he has had four additional doses of oral immediate-release morphine over the past 24 hours, this means he has had 4 x 5 mg additional oral morphine (that is, 20 mg in total over that period of time)

To add this to his oral sustained-release regimen of morphine 15 mg twice daily, he could be titrated to oral sustained-release morphine 25 mg twice daily

Scenario 8: Arthur


He finds the rescue dose of immediate-release morphine helpful but the nursing staff tell you he is very reluctant to ask for them and only ‘bothers them’, as he puts it, when he is in severe pain

The healthcare assistant on the ward tells you that she had a chat with him and established that he is worried he will get ‘hooked on the morphine’ and that it will kill him eventually

Scenario 8: Arthur

8.5 Question

How do you address this?

Scenario 8: Arthur

8.5 Answer

Establish what his concerns are, and what his ideas about morphine and strong opioids are. It is likely that he has worries and preconceptions about morphine, for instance, he may think morphine signifies the imminent end of his life or that it will kill him

Address ideas about addiction and discuss the concept of dependence


Scenario 8: Arthur


Reassure him that he should request medication when he is in pain, that staff are there to help, and that by ensuring his pain is well controlled it is easier to find the best stable dose of medication for his pain

You should offer him a follow-up consultation to discuss these matters further and to offer him the chance to ask further questions

Scenario 8: Arthur


He deteriorates rapidly one evening and is found to be in renal failure. He appears to be getting opioid toxicity (drowsiness, hallucinations and myoclonic jerking), but is also in a lot of pain. His regular ibuprofen is discontinued

8.6 Question

What approach would you take with regard to his pain management, now that he has gone into renal failure?

Scenario 8: Arthur

8.6 Answer

His hospital team should obtain specialist palliative care advice about ongoing pain-control and what medication, mode of delivery and doses to choose

Part 3

108

Post-workshop quiz

Now complete the post-workshop quiz

?

• What can we do to implement these recommendations in our organisation?

• What modifications do we need to make to our current practice/documentation around prescribing and the use of opioids for people with advanced and progressive disease to implement the recommendations?

Discussion

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