1. Pain Management in Palliative Care
Dr Tasha Nishiyama

2. Aim and Objectives
To think about pain assessment and how this may alter your management
To learn about opioids and how to calculate and convert doses
To write FP10 prescriptions for controlled drugs
To prescribe a syringe driver and other subcutaneous medications for the DNs

3. Key Points About Pain A good pain history is vital
Aim to treat the cause of the pain (remember that the pain may not be related to cancer)
Some pains are only partially opioid responsive
Some pains respond better to other medications e.g. NSAIDs, steroids, amitriptyline etc
Remember non drug treatments e.g. radiotherapy or surgery

4. Analgesic Ladder Step 1: paracetamol
Step 2: weak opioids e.g.codeine, dihydrocodeine
Step 3: stong opioids e.g. morphine, oxycodone, fentanyl, buprenorphine
Adjuvants include: NSAIDs, corticosteroids, antidepressants, anticonvulsants and benzodiazepines

5. Opioids Safe drugs if administered and titrated appropriately
See conversion chart
Gold standard for strong opioids is morphine orally or morphine/diamorphine subcutaneously
Important to calculate carefully – the safest way is to convert back to oral morphine and convert out from oral morphine
If in doubt get someone to check your calculations

6. Side Effects - Opioids Constipation
Nausea and vomiting – although often transient and controllable
Drowsiness – often dose related and temporary
Respiratory depression – although shouldn’t occur if doses are titrated appropriately
Consider prescribing laxative and antiemetics

7. Case 1
A 76 year old lady with locally advanced ovarian cancer comes to see you complaining of lower abdominal pains which she describes as a constant ache. She is already taking 2 co-codamol 30/500 QDS. She feels that this isn’t helping as much as it used to. She is otherwise feeling well in herself. Her bowels are regular and she has had no urinary symptoms. Her abdomen is soft but a little tender over the lower quadrants. Her bowel sounds are normal. You decide to increase her analgesia. How do you go about this?

8. Case 1
As the patient has been taking regular opioid analgesia it would be safe to convert them straight to a modified release morphine e.g. MST – starting dose would be 10-20mg MST BD.
Alternatively convert them to regular oramoprh 5-10mg QDS with a view to converting to a modified release preparation when the pain is stable
In both cases the patient needs to be prescribed or have instructions about using oramorph for break through pain

9. Case 1
The patient is commenced on 15mg MST BD. What would is the breakthrough dose of oramorph?
What would you tell the patient about how to use it?

10. Breakthrough Pain
All patients on MR morphine should have immediate release morphine to use for breakthrough pain.
Two forms – oramorph (liquid) or sevradol (tablets)
The dose is calculated as a sixth of the 24 hour morphine dose. In this case the breakthrough dose would be 5mg
For oramorph be careful about the difference between millilitres and milligrams. Standard strength oramorph is 10mg/5mls. So to give a dose of 5mgs the patient needs to be advised to take 2.5mls
Short acting morphine tends to last for 4 hours – normally tell the patient they can take it 2-4 hourly but to contact the doctor if needing more than 3-4 doses/day

11. Case 1
You visit the patient several weeks later. She has been seen by one of your colleagues in the meantime and her MST has been increased to 30mg BD. She is getting on well with the MST and hasn’t suffered any side effects. She has been keeping a list of the times that she has used the oramoprh. You can see from this list that on average she has required 3 doses (10mg) a day on top of her MST. With the extra doses her pain is much improved. What changes are you going to make to her medications?
Write a FP10 for her new prescription

12. Write an FP10
If prescribing a controlled drug on an FP10 the quantity i.e. the number of tablets needs to be given in words and figures
Remember to check the drug strengths available as may need to prescribe 2 strengths to give one dose
Prescribe by brand e.g. MST Continus

13. FP10 for Case 1
Increase MST dose to 45mg BD (was taking a total of 60mg of MST + 30mg oramorph in 24 hours)
Increase the oramorph dose to 15mg PRN
Need to write a prescription for 2 different doses of MST as no 45mg tablets available (15mg + 30mg)
MST Continus is available in 5mg, 10mg, 15mg, 30mg, 60mg, 100mg and 200mg tablets. It is also available in sachets of granules that can be mixed to make a suspension
Other 12 hourly release morphines are morphgesic SR and Zomorph. MXL is a 24 hour release morphine

14. Case 2
A 68 year old with breast cancer is deteriorating. She had been taking 90mg MST BD but over the last few days has becoming increasingly sleepy. It seems as though her disease is progressing. Her pain has been well controlled. You are asked to assess her as her husband reports that she is now struggling to take her tablets, is drinking occasional sips only and is now being nursed in bed. When you arrive, she is settled and is able to have a short conversation. How would you manage her pain?

15. Case 2
This patient is likely to need a syringe driver as she is no longer managing to take her tablets. As her pain seems to be well controlled on 90mg BD MST a direct conversion seems to be appropriate.
Write a syringe driver prescription for the district nurses on the pink prescriptions sheets. Also complete the sheet for breakthrough/anticipatory medications.

17. Syringe Driver Prescription
Sample Prescription
Syringe driver prescription should contain either 60mg diamorphine/24 hours or 90mg morphine/24 hours

18. Prescription of Anticipatory Medications
Sample Prescription Sheet
Breakthrough analgesia should be diamorphine 10mg or morphine 15mg (she can still use 30mg oramorph as is she is able to tolerate it)
Other anticipatory meds – haloperidol, midazolam and buscopan

19. First Line Anticipatory Medications
Pain – Morphine or Diamorphine (use the same as whatever is in the syringe driver). Doses dependant on background analgesia
Nausea and Vomiting – Haloperidol 1.5-3mg (max dose in 24 hours = 10mg)
Respiratory Tract Secretions – Buscopan 20mg (max dose in 24 hours = 120mg)
Aggitation – Midazolam 2.5-5mg (normally give an initial max dose of 25mg/24 hours)
Dyspneoa – morphine/diamorphine as above

20. Syringe Drivers
Used for symptom control when other ways of administering the medication is unsuitable or inadequate
Uncontrolled pain on it’s own is NOT an indication for a syringe driver
It can take several hours after commencing a syringe driver before it reaches therapeutic levels (may want to consider giving a bolus dose at the start)
The syringe needs to be changed every 24 hours – this is done by the DNs or hospice at home team
NOTE: not all drugs can be mixed in a syringe driver. Compatibility must be checked. Information can be found at or by contacting the palliative care team

21. Case 3
A 31 year old patient with a spindle cell carcinoma of his right arm is deteriorating. His pain has been difficult to control. He currently has 150μg/hour of fentanyl patches in situ. He already has a syringe driver with 90mg ketorolac (NSAID). Over the past 24 hours he has stopped taking anything orally. The district nurses have been attending multiple times a day and he has had an extra 120mg diamorphine in the past 24 hours. The patient clearly states that he wants to be nursed at home. The district nurses have requested a visit as they feel that his analgesia needs increasing. How would you address his pain?

22. Case 3
This patient needs his analgesia increasing. The best way to do this would be via a syringe driver.
Fentanyl patches can be increased but they take hours to become effective and so a syringe driver would be more appropriate for uncontrolled pain.
Similarly the patches take hours for their effects to wear off and so if they were to be taken off it would require some close titration of the syringe driver/analgesia over this time (not likely to be achievable in the community)
For patients with fentanyl patches already in situ the easiest way to do this is to leave the fentanyl patches on and start a syringe driver that just takes into account the extra analgesia he has required. In this case up to 120mg diamorphine/24 hours

23. Case 3
Breakthrough analgesia for this case can be calculated as follows:
150 fentanyl patch (x3.6) = 540mg oral morphine
120mg diamorphine (x3) = 360mg oral morphine
Total daily oral morphine = = 900mg
Total daily diamorphine = 900 ÷ 3 = 300mg
Breakthrough diamorphine = 300 ÷ 60 = 50mg
As a rule it is best to give the same drug PRN and in the driver.

24. Oxycodone Strong opioid with similar properties to morphine.
Used second line (usually patients unable to tolerate morphine)
Available as a MR preparation know as Oxycontin
Immediate release oral preparation is Oxynorm
If prescribed subcutaneously then should be prescribed as oxycodone
Useful in patients with renal failure as tends to accumulate less

25. Fentanyl Trans-dermal administration via a patch
Need to be changed every 72 hours
Suitable for patients with severe chronic pain (long half life – as per case 3)
Patches available in 12, 25, 50, 75 and 100μg/hr strengths
May have more than one patch on to make doses not otherwise available (e.g = 37μg/hr)
Patients with a fentanyl patch should have oramorph first line for breakthrough pain
Short acting preparations are available but these should only be prescribed on the advice of palliative care.

26. Buprenorphine
Trans-dermal patch (long acting) or sublingual tablets (short acting)
Patches useful for chronic pain (long half life)
Two different types of patch:
BuTrans: available in 5, 10, 20 μg/hr. Need to be changed every 7 days. May not reach full effect for 72 hours
Transtec: available in 35, 52.5 and 70 μg/hr. Need to be changed every 96 hours. May not reach full effect for 24 hours

27. Adjuvants
NSAIDs – especially useful in bone, musculoskeletal and liver capsule pains (can be given subcutaneously – ketorolac). Consider PPI cover.
Corticosteroids – used for raised ICP, nerve or cord compression and liver capsule pain. Dexamethasone most commonly used.
Amitriptyline – neuropathic pain. Very useful if the patient is also depressed
Gabapentin/Pregabalin – neuropathic pain
Don’t forget the anxiolytics (as anxiety can be a big contributing factor) e.g. diazepam or lorazepam

28. Useful Sources Of Information
YCN Guide To Symptom Management In Palliative Care (
Palliative drugs (need to register but is free)
Palliative Care Handbook (includes an opioid conversion calculator)
Bradford and Airedale Palliative Care

29. Further Advice Colleague at the practice
Macmillan Nurses – can be contacted on
Palliative Care Consultant (on call 24/7) – can be contacted via the hospice on

31. Summary Pain is the most commonly seen symptom in palliative care
It can be managed in many ways - it is important to try and establish why the patient has pain.
Remember adjuvants and non drug treatments
Opioids are generally safe if titrated correctly
Be careful if calculating conversions
There is always someone available to ask