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 Next steps for management 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 Next steps for management 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 Next steps for management 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 Next steps for management 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) Continues on next slide

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 Continues on next slide

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 Continues on next slide

Scenario 2: Helena 2.5 Answer: continued 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 Past medical history 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 Next steps for management 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 Continues on next slide

Scenario 3: Vera 3.1 Answer: continued The typical daily starting dose should be mg sustained-release oral morphine 12 hourly plus rescue doses of 5 mg immediate-release oral morphine for breakthrough pain or mg immediate-release oral morphine 4-hourly plus rescue doses of 5 mg immediate-release oral morphine for breakthrough pain

Scenario 3: Vera Next steps for management 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: Vera 3.3 Answer Laxatives Next steps for management 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 Continues on next slide

Scenario 3: Vera 3.4 Answer: continued 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 Next steps for management 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 Past medical history 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 Continues on next slide

Scenario 4: Bill On 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 Next steps for management 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: Bill 4.3 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 Past medical history 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 Next steps for management 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 Next steps for management 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 Next steps for management 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 Past medical history 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 Continues on next slide

Scenario 6: Maria 6.2 Answer: continued 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 Past medical history 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 Next steps for management 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 Next steps for management 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 Next steps for management 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 Past medical history 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 Next steps for management 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 Continues on next slide

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 8.1 Answer: continued 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 Continues on next slide

Scenario 8: Arthur 8.3 Answer: continued 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 Next steps for management 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 Continues on next slide

Scenario 8: Arthur 8.4 Answer: continued 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 Next steps for management 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 Continues on next slide

Scenario 8: Arthur 8.5 Answer: continued 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 Next steps for management 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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