Key notes on symptom control issues in Palliative Care

Short acting opioids. Are the drugs of choice for visceral pain. If a patient is already on the maximum dose of a step 2 analgesic, then the starting dose of oral morphine sulphate is 10mg every four hours, with the same dose for breakthrough pain. The dose should be titrated against the pain using increments set out in the table. Only consider starting doses of oral morphine sulphate of less than 10mg if the patient is in renal failure, is very frail or has not been on a maximum step 2 analgesic. Once adequate pain relief has been obtained convert the total dose of oral morphine sulphate taken in 24hours (including break through doses) to a long acting formulation. Always ensure you have prescribed the equivalent four hourly dose for breakthrough.

4hrly morphine sulphate 5mg 10mg 15mg 20mg 30mg 40mg 60mg

dose increments renal normal seek specialist

failure starting dose advice

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  Consider prescribing haloperidol 3mg as an anti-emetic if the patient is at risk of opioid induced nausea and vomiting. Warn patients about the possibility of short-term drowsiness as the morphine sulphate is started. For most patients this wears off after 3-4 days.
  
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  There is no ceiling dose of oral morphine sulphate but specialist help should be sought if the 24hour dose of morphine sulphate exceeds 360mg (60mg every four hours).
  
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  Alternative opioids that may be used under the direction of a specialist are fentanyl, hydromorphone and oxycodone.
  

Bone pain

Bone pain
Step one	Diagnose the cause and treat if possible	Start an NSAID
Step two	Follow the WHO ladder	Consider radiotherapy
Step three	Trial of steroids	Ask for help

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  Non-steroidal-anti-inflammatory drugs (NSAIDs). Start with the maximum dose of the NSAID. The dose may be titrated down if good pain relief is achieved. The choice of which NSAID to use will depend on the route of administration as well as a risk / benefits analysis. Use appropriate GI protection with either a proton pump inhibitor or misoprostol in at risk patients.
  
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  Consider referral to a clinical oncologist for palliative radiotherapy
  
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  Orthopaedic intervention for large bone metastases may be appropriate and improve pain control.