16.1 Pain due to cancer in adults- Palliative Care

• Analgesia should be titrated in each patient according to response and side effects
• Analgesia for breakthrough pain (i.e. prn doses) should always be available
• Non-opioids can be continued and combined with step 2 and step 3 analgesics if they are beneficial and tolerated
• Check renal function before starting NSAID and/or opioid and continue to monitor
• Patients with significant renal or hepatic impairment require special consideration with regard to choice and dose of opioid
• Consider the type of pain being treated e.g. bone pain may be NSAID sensitive

The WHO analgesic ladder

Non-opioid

Recommended:

Paracetamol - oral preparations (TLS Green)

Ibuprofen (TLS Green)

Naproxen (TLS Green)

Alternatives:

Diclofenac (TLS Blue)

Paracetamol (intravenous & rectal) (TLS Blue)

Specific indication:

Ketorolac subcutaneous injection (TLS Amber specialist recommended)

• Under specialist advice only

Opioids for mild to moderate pain

Recommended:

Codeine – ideally as co-codamol 30/500 (TLS Green)

• If not tolerated in this formulation, or to allow individual drug dose changes, can be prescribed as separate paracetamol and codeine

Alternative:

Tramadol (TLS Blue)

Opioids for moderate to severe pain

NICE CG140 Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults

Recommended:

Morphine (TLS Green)

• Liquid or immediate-release tablets
• Modified-release capsules or modified-release tablets

Morphine sulphate injection (TLS Green)

• 10, 15, 20, 30mg/mL and 60mg/2mL

Alternatives:

Oxycodone (TLS Blue)

• Modified release - use tablets
• Immediate release - use capsules or oral solution
• Oxyact^® brand - non-formulary

Diamorphine injection (TLS Blue)

• 5, 10, 30, 100, 500mg ampoules

Transdermal patches

• Fentanyl 25microgram/hr patch delivers between 60-120mg oral morphine equivalent every 24 hours
• Use patches only:

1. When patients have stable pain
2. Pain is opioid responsive but there are intolerable side effects with morphine or other opioids
3. For patients who have difficulty with oral route

• There are two types of patch available – a reservoir patch where the drug is held in solution and a matrix patch where the drug is distributed evenly throughout a matrix. As patches vary considerably in their appearance, and to avoid the risk of patient confusion, patients should not be changed from one formulation or make to another without adequate counselling

Fentanyl transdermal patches (TLS Blue)

• 12, 25, 50, 75, 100micrograms/hr

Buprenorphine transdermal patches (TLS Blue)

Fentanyl citrate injection for subcutaneous use (TLS Blue)

• 50micrograms/mL

Hydromorphone (TLS Blue)

• Capsules immediate-release

• Capsules modified-release

Specific Indication:

Hydromorphone (TLS Blue)

• Renal failure (eGFR <30mLs/min)

Fentanyl (TLS Blue)

• Renal failure (eGFR <30mLs/min)

The following drugs only to be initiated after discussion with palliative care or chronic pain team

For breakthrough/incident pain

Fentanyl sublingual tablets (Abstral^®) (TLS Blue)

Alfentanil nasal / buccal / sublingual spray (TLS Blue)

• Made on named patient basis by Torbay pharmaceuticals in patients with severe renal impairment/morphine intolerance

Alfentanil injection 500micrograms/mL, 5mg/mL (TLS Blue)

• For subcutaneous use with patients with severe renal impairment/morphine intolerance; if volume restriction prevents use of lower strength

Oxycodone injection 50mg/mL for subcutaneous use (TLS Blue)

Hydromorphone injection (TLS Blue)

• Available on a named patient basis
• For complex pain

Methadone (TLS Blue)

• Under specialist guidance ONLY

Adjuvant Medication for Treating Neuropathic Pain

NICE CG173 Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings

Recommended:

Amitriptyline tablets/liquid (TLS Green)

Gabapentin capsules (TLS Green)

Alternatives:

Pregabalin (TLS Blue)

• Caution – Use Pregabalin with caution in women of childbearing age. Effective contraception should be used during treatment and avoid use in pregnancy unless clearly necessary – see MHRA Drug Safety Update (April 2022)

Special indication:

Clonazepam tablets / injection for subcutaneous use (TLS Blue)

Dexamethasone if acute nerve compression suspected (TLS Blue)

Ketamine under specialist guidance ONLY (TLS Red)

Lidocaine patches (TLS Amber Specialist Recommended)

• On recommendation of palliative care only

Lidocaine patches are low value medicines that should not be routinely prescribed in primary care as per NHS guidelines

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