1. By Dr Marie Joseph MB BS FRCP Medical Director & Consultant in Palliative Medicine St Raphael’s Hospice, Surrey and Macmillan Consultant, Epsom & St Helier Universities NHS Trust mariejoseph@straphaels.org.uk March 2009

2. Content Allaying ‘post-Shipman anxiety’ Pain and distress in the dying The WHO analgesic ladder Principles of opioid therapy Cardinal features of opioid toxicity Opioid switch Opioid equivalences Opioids in renal failure Providing comfort in the dying stage Summary

3. Allaying ‘Post-Shipman anxiety’ How much is too much? Pressure from distressed relatives The doctrine of double effect Death due to disease, (not due to drug)...opposite of euthanasia Regular, patient supervision/professional support

4. Pain and distress in the dying patient Escalating/unabating physical pain Emotional pain of leaving loved-ones behind Inability to communicate Yearning for comfort and dignity Inevitable carer/professional distress

5. The WHO Analgesic Ladder Non-opioid ± Adjuvant Non-opioid ± Adjuvant Opioid for mild to moderate pain ± Non-opioid ± Adjuvant Opioid for mild to moderate pain ± Non-opioid ± Adjuvant Opioid for moderate to severe pain ± Non-opioid ± Adjuvant Opioid for moderate to severe pain ± Non-opioid ± Adjuvant

6. Principles of opioid therapy Unstable pain requires titration with regular, 4-hourly, short acting opioid [same dose PRN] Always use appropriate laxative (i.e. Softener and stimulant e.g. Movicol/Codanthramer) Approximately 1 / 3 rd need anti-emetic therapy (if prone to migraine/vestibular disorder) Increase dose by 30-50% if pain inadequately controlled (and patient not opioid toxic) PRN dose is 1/6 th of the total 24 hr dose

7. Cardinal Features of Opioid Toxicity Excessive drowsiness Myoclonic jerks ‘Insect-type’ visual hallucinations ‘Pin-point’ pupils Caution: May be opposed by anti-cholinergic medications e.g. Cyclizine, Amitriptyline) NOTE: Respiratory depression virtually never encountered with due vigilance as above.

8. Opioid switch Indications Inadequate analgesia + OPIOID toxicity Idiosyncrasy to one type of OPIOID e.g. not uncommonly, MORPHINE OXYCODONE in neuropathic pain

9. Opioid equivalences ORAMORPH 15mg [  oral Oxynorm 7.5mg]  1/ 3 DIAMORPHINE sc 5mg  1/ 10 ALFENTANIL sc 500mcg ½

10. Opioid equivalences cont.... Durogesic (Fentanyl) 12mcg patch every 72 hours  Oramorph 5-10mg 4 hourly Butrans patch weekly(BUPRENORPHINE) (5mcg 10mcg 20mcg)....... Entirely STEP 2 of WHO analgesic ladder Buprenorphine 35mcg Matrix patch (Transtec) every 72 hours or twice a week  Oramorph 5-10mg 4 hourly

11. Opioids in renal failure Fentanyl/Alfentanil safer If using Morphine: Caution:  decrease dose and frequency If using Alfentanil in CSCI (continuous subcutaneous infusion)  Dose is 1/ 10 th of Diamorphine dose  Use Oxycodone SC prn for breakthrough analgesia

12. Providing comfort in the dying stage PAIN  Use Diamorphine via CSCI ( 1 / 3 rd of 24 hour oral Morphine dose) OR Initially 5-10mg/24 hours if Opioid Naive RESTLESSNESS  Exclude distended urinary bladder  Attend to spiritual needs  Use Midazolam via CSCI (10-20mg/24 hours...100mg/24hours)

13. Providing comfort in the dying stage.... Cont. VOMITING  Use Levomepromazine via CSCI (initially 3.125-6.25mg/24 hours......75mg/24 hours) LUNG SECRETIONS  Use Hyoscine Hydrobromide via CSCI (initially 0.6-1.2mg/24 hours... 2.4mg/24 hours) Note:-Regular patient review -Comfort family -Support inter/disciplinary team

14. Summary OPIOIDS are safe and effective in the dying Importance of familiarity with ‘Principles of opioid therapy’ Regular patient review essential Reassurance of Specialist Palliative Care Team support always

15. Thank you