GP Clinical Governance Meeting 13 th of July 2011 Dr Marion Lieth Consultant in Palliative Medicine, Bolton Hospital and Bolton Hospice Common issues: Opioid Prescribing and LCP

Outline Common things about opioids: Some basics about prescribing opioids Common side effects and how to deal with them Fentanyl patch Opioid switch Care of the dying Case scenarios for discussion – Prescribing for LCP

Strong Opiates Used in Palliative Care Morphine (oral, subcut) Oxycodone (oral, subcut) Diamorphine ( subcut) Fentanyl (transdermal, buccal, transmucosal) Alfentanyl (subcut) Hydromorphone (oral, subcut) Buprenorphine (transdermal) Methadone

Some basics about opioids All strong opiates provide effective analgesia All have the same potential side effects. Tolerated differently by different patients depending upon the dose required and coexisting factors eg renal function Use oral route if possible Morphine is 1 st line Start small, give regularly, review often and titrate NPSA alert – max 30-50% increase Patient factors, pain intensity, side-effects PRN dose depends on total 24 hour dose In general 1/6 th Provide explanations and deal with concerns

Common side effects Nausea and vomiting often in the first days, occasionally persistent Metoclopramide or haloperidol Constipation Stimulant + softener laxative A sense of drowsiness, often improves after a few days Confusion (particularly the elderly) Small initial dose and titrate slowly, check renal function, warn the patient

Neurotoxic side effects Hallucinations Bad dreams Myoclonus Delirium Drowsiness  Dose and patient dependent  Poor renal function  Check RF, reduce dose, switch opioid

Serious side effects Drug dependence: common fear rare if prescribed and used properly Respiratory depression: Rare if prescribing guidelines are followed

Fentanyl patch Not better then any other opioid Non-oral route E.g. Head and neck cancers Useful in renal failure Compliance Slow to titrate Not good for acute or unstable pain Potent analgesic Fentanyl 25mcg her hour = ??? oral Morphine over 24 hrs

Fentanyl patch Not better then any other opioid Non-oral route E.g. Head and neck cancers Useful in renal failure Compliance Slow to titrate Not good for acute or unstable pain Potent analgesic Fentanyl 25mcg her hour = 60-90mg oral Morphine over 24 hrs Codeine 240mg a day = ???? oral Morphine over 24 hours

Fentanyl patch Not better then any other opioid Non-oral route E.g. Head and neck cancers Useful in renal failure Compliance Slow to titrate Not good for acute or unstable pain Potent analgesic Fentanyl 25mcg her hour = 60-90mg oral Morphine over 24 hrs Codeine 240mg a day = 24mg oral Morphine over 24 hours

Opioid switch – Reasons: One opioid does not work better then other Patient preference Problems with route of administration Side effects; intolerable, dose limiting Renal failure Volume of injection

Principles of Conversions Convert for the right reasons Confirm the analgesia used so far Don’t guess, use tables and calculations Tables are only a guide – if high doses convert conservatively and titrate Review the outcome of the drug change and adjust the dose if necessary

Basic Conversions Fentanyl patch 25mcg/hour is equivalent to about ??? mg of oral morphine per day. Potency oral codeineoral morphine sc morphine oral morphineoral Oxycodone oral oxycodonesc oxycodone oral morphinesc diamorphine

Basic Conversions Fentanyl patch 25mcg is equivalent to about mg of oral morphine per day. Potency oral codeineoral morphine1:10 oral morphinesc morphine1:2 oral morphineoral Oxycodone1:2 oral oxycodonesc oxycodone1:2 oral morphinesc diamorphine1:3

Analgesia when patient is dying If analgesia hasn’t been required so far prescribe morphine mg sc prn If on regular strong opioids by mouth Convert regular long-acting opioid dose to sc sc Morphine if on oral morphine sc Oxycodone if on oral oxycodone divide the oral dose by 2 Timing? Prescribe PRN (a sixth of 24hr dose)

Fentanyl patches and syringe drivers Continue the fentanyl patch Write up PRN opioid dose If in pain: Add morphine or oxycodone to the syringe driver ‘Rule of thumb’ – start syringe driver with 2x prn dose over 24 hours = 30% increase Recalculate PRN dose Fenanyl patch + syringe driver

Any questions?

Q 1. A district nurse contacts you to suggest a patient is started on the LCP. The patient has been taking 90mg of morphine MR bd and two additional doses of morphine soln 30mg each day. How would you respond to this and what do you prescribe?

Answer 1. Why does she think that the patient is dying? Check history, drugs, exclude reversible factors Has pain been well controlled on the oral morphine? If you think a syringe driver is required and depending on above and your assessment: MST 90mg bd + Oramporph 30mgx2 240mg oral morphine per day 120mg morphine sc/24hrs 20mg morphine sc prn

Q 2 A district nurse contacts you to suggest a patient is started on the LCP. The patient has been taking 200mg Oxycontin bd and the pain has been well controlled on this. There are no reversible factors, the patient is dying and unable to swallow. What do you prescribe?

Answer 2 Switch to sc infusion Oxycontin 200mg bd Oral Oxycodone 400mg over 24 hours Oxycodone 200mg sc over 24 hours Concentration in ampule: Oxycodone 10mg/ml  20 ml Maximum volume in syringe driver? 20ml syringe holds 16-17ml 30ml syringe holds 22ml

Answer 2 3 options: Why Oxycodone? 1. Use 30ml syringe, e.g. holds 22ml – but little volume left for other drugs 2. Switch to Diamorphine Oral Oxycodone 400mg/24 hours Oral Morphine 800mg/24 hours Sc Diamorphine 800 divided by 3 = 260mg sc Diamorphine /24 hours 3. Ring Hospice advice line Confirm numbers Other options – e.g Alfentanyl

Q3 A patient started on a fentanyl patch only last week. The dose is now 50mcg. The patient continues to have pain and needs prn morphine 10mg every 2 hours or so. The district nurse requests review. She thinks a syringe driver is indicated. What do you suggest?

Answer 3 What about the pain? does the prn morphine help? Prn dose appropriate? Can patient take oral Morphine? Is the oral morphine absorbed? How many prn doses exactly? Are there other causes of distress? Is the patient opioid toxic? Try appropriate PRN Morphine dose – 30mg oral, 15mg sc morphine Use of syringe driver and dose depends on these answers If able to take by mouth – regular oral Morphine Morphine sc 30-60mg/24 hr could be reasonable. Continue the patch

Q4 A patient has a fentanyl patch 75mcg in place and 60mg morphine in a syringe driver. What is the correct prn dose of morphine?

Answer 4 The prn dose should be calculated by thinking about both the patch and the morphine infusion, ie the total 24 hr dose of opiate 3 Different ways: 1. PRN for each and add together: Fentanyl patch 75mcg/hr  prn oral morphine 40mg  prn sc morphine 20mg Morphine sc infusion 60mg/24h  prn 10mg sc morphine Therefore: PRN sc morphine = 30mg

Answer 4 2. Convert to total oral daily dose, then PRN for total Fentanyl patch 75mcg/hour  equivalent oral Morphine 270mg/24hours Morphine sc infusion 60mg/24 hours  Equivalent oral Morphine 120mg/24hours Total equivalent oral Morphine dose 390mg/24hours PRN oral Morphine 60mg PRN sc Morphine 30mg 3. Ring a friend Bolton Hospice Advice line –

Q5 You have seen a patient who you think is dying. After discussion with the family and district nurse you commence the LCP. The patient normally takes Oxycodone 30mg bd and Cyclizine 50mg tds. His symptoms are well controlled on this. What do you prescribe?

Answer 5 Switch regular Oxycontin to syringe driver Continue regular anti-emetic Anticipatory prescribing for other common symptoms of dying patient – PRN medication Pain Nausea Respiratory secretions Distress/Agitation Breathlessness

Answer 5 This patient is on Oxycontin 30mg bd, Cyclizine 50mg tds Syringe driver: Oxycodone 30mg sc infusion over 24 hours Oxycodone and Cyclizine are not compatible in syringe Levomepromazine mg sc infusion over 24 hours Anticipatory PRN medication: Oxycodone 5mg sc Levomepromazine 6.25mg sc 4-6 hourly Hyoscine hydrobromide 400microgram sc Be aware – similar name – Hyoscine butylbromide (Buscopan) Midazolam mg sc, max 20mg over 24 hour If requires more – needs review

Advice Guidelines Conversion charts The palliative care team are always happy to help Bolton hospice advice service Tel

New syringe drivers Recent NPSA alert In Bolton acute hospital, community services and hospice have switched from Graesby pumps to McKinley T34 syring drivers on 15 th of June 2011 Nursing staff have been trained in new device No difference for prescribing Maximum volume remains unchanged 17ml in 20 ml syringe 22ml in 30 ml syringe