‘Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness’ recommends that patients at risk of suicide, including all patients with a recent history of self-harm, who are treated with psychotropic drugs should receive modern, less toxic drugs and/or supplies lasting no more than 2 weeks.
1. It is important that analgesics are given regularly for chronic pain as they are more effective in preventing than relieving pain. Adequate doses of non-opioids given regularly will often make the use of opioids unnecessary.
2. Analgesics have a 'dose ceiling' with regard to efficacy, and the variable side-effect profile up to the maximum useful dose will influence the choice of a particular analgesic.
For advice on pain relief in palliative care see BNF Prescribing in Palliative Care, Joint Formulary Palliative Care Guidelines (chapter 16) and contact the medical staff at:
Mount Edgcumbe Hospice - 01726 65711
St Julia's Hospice - 01736 759070
St Luke's Hospice - 01752 401172
Guidance on other supportive treatments may be obtained from the Pain Relief Clinic at Royal Cornwall Hospital Trust - 01872 252792
1. NPSA Rapid response July 2008: reducing dosing errors with opioid medicines
When opioid medicines are prescribed, dispensed or administered, in anything other than acute emergencies, the healthcare practitioner concerned, or their clinical supervisor, should:
Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic medicines prescribed for the patient. This may be done for example through discussion with the patient or their representative (although not in the case of treatment for addiction), the prescriber or through medication records.
Ensure where a dose increase is intended, that the calculated dose is safe for the patient (eg for oral morphine or Oxycodone in adult patients, not normally more than 50% higher than the previous dose).
Ensure they are familiar with the following characteristics of that medicine and formulation: usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, common side effects.
2. In the post-operative period, patients should be closely monitored for adequate pain relief as well as for signs of possible side-effects especially respiratory depression. RCHT has produced its own 'intramuscular analgesia guidelines'.
3. Morphine must be given regularly every four hours (unless m/r preparations). If pain recurs because of prn dosing it is likely that increased amounts of analgesia may be needed to regain pain control.
4. The use of m/r morphine preparations requires a sufficient length of functioning small intestine to ensure absorption.
5. Fentanyl patches are used only for opioidsensitive pain and not as a routine first line opioid analgesic. Hence, they are used in palliative care and by the Pain Team for chronic pain only.
6. Abstral buccal tablets and Pecfent nasal spray are for specialist initiation for the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain where other short-acting opioids are not appropriate. Prescribers should be aware of the different pharmacokinetics of the transmucosal fentanyl preparations; doses are not interchangeable.
7. Routine laxative treatment - 'softener' eg lactulose plus 'pusher' eg senna or a compound preparation (dantron only if terminally ill) - should be considered for patients requiring an opioid for any length of time. However, patients with a colostomy / ileostomy, even when on strong opioids, do not commonly need a significant 'pusher' - lactulose or docusate may be quite adequate.
8. Methadone tablets are also used in palliative care. Tablets must not be prescribed for addicts (for drugs of addiction see section 4.10).
9. Pethidine is not suitable for severe continuous pain because of its short half life. Traditionally it has been used for renal colic but there is little evidence to support this indication.
10. Modified-release dihydrocodeine is not included, as there is no evidence to show it is of benefit against more frequent dosing.
Approximate oral analgesic equivalence to morphine
The dose of opioid should be multiplied by its potency ratio to determine the equivalent dose of morphine sulphate.
Analgesic Potency ratio with oral morphine
Codeine 1/10
Dihydrocodeine 1/10
Oxycodone 1.5 to 2
Methadone 5 to 10
Hydromorphone 7.5
Fentanyl (transdermal) 150