Terminal-stage patients 'need stronger pain relief'

Many patients with “advanced cancer and other debilitating conditions” aren’t being given strong enough pain relief, BBC News has reported. This is thought to be due to doctors being reluctant to prescribe strong opioids, such as morphine, partly as a result of patients’ concerns over addiction. Patients may also wrongly assume that they are nearer the end of their life, as there is a misconception that opioids are only given during the final stages of terminal disease.

The news is based on new medical guidelines on the safe and effective prescribing of strong pain-relieving drugs for people living with and dying from a terminal condition (palliative care). The guidelines, issued by the National Institute for Health and Clinical Excellence (NICE), are designed to help medical staff prescribe doses that improve both pain levels and quality of life. They also address side effects such as drowsiness and misconceptions about becoming addicted to opioid medication.

Pain is a common fear for people with advanced or progressive disease but it can be controlled well with appropriate medication. This includes opioids, which, while susceptible to side effects like any other drug, are effective when prescribed appropriately.

What do the new guidelines cover?

Opioid drugs such as morphine offer some of the strongest pain relief available, but their use also carries certain side effects, such as a risk of extreme drowsiness and nausea. Due to their power they are generally prescribed to people in extreme pain, such as people with advanced cancer, but prescribing too low a dose or avoiding the use of opioids altogether can leave patients struggling with their pain. Equally, prescribing too large a dose can make a person too drowsy and weak, diminishing their quality of life.

This new clinical guideline sets out advice on the safe and effective prescribing of strong opioids for relieving pain in adults with advanced and progressive disease. Providing this kind of pain relief is often referred to as "palliative care". The guidance aims to improve pain management and patient safety but does not include care during the last days of life, otherwise known as end-of-life care. The guidelines have been issued by the National Institute of Health and Clinical Excellence (NICE), which sets out the guidance and standards for treating specific conditions and disease within the NHS in England and Wales.

The guidance looks specifically at five pain-relieving opioids (morphine, diamorphine [heroin], buprenorphine, fentanyl and oxycodone) and provides advice on offering pain treatment and the key considerations that need to be addressed when setting doses that offer adequate pain relief. It also provides advice on the management of some side effects associated with taking these drugs, including constipation, nausea and drowsiness.

The guidelines further recommend that doctors discuss any concerns that patients (and their families) may have about addiction, tolerance, side effects and any concerns that treatment with strong opioids signals that a patient is entering the final stages of their life.

When is palliative care given?

Palliative care is a specialist type of care provided for all people living with and dying from a terminal condition. The aim is to help the person live as well as possible and avoid suffering wherever possible. The goal with this type of care is to improve quality of life for patients and their families by providing care that addresses the patient’s individual needs physically, emotionally, spiritually, socially and culturally.

Palliative care is provided by a range of health professionals, including GPs and specialist palliative care doctors and nurses. It can be provided in the home, a hospital, an aged care home or a hospice. End-of-life care is part of palliative care.

Pain is common in advanced and progressive disease, and up to two thirds of people with cancer experience pain that requires a strong opioid. For patients experiencing pain, opioids are often prescribed to relieve this pain. Opioid drugs come from either the opium poppy or are artificially produced. Strong opioids, such as morphine, are painkillers that act on the central nervous system to relieve severe pain. There is no standard dose of a strong opioid and the amount needed to control pain varies from person to person. Being offered strong opioids can happen at different stages in the course of a disease and it doesn’t necessarily mean a person is close to the end of their life. However, there is a common concern that patients might perceive the use of opioids in this way, and become distressed.

Why are doctors under-medicating?

Evidence suggests that despite increased availability of strong opioids in the UK, pain resulting from advanced disease often goes untreated. NICE reports that “misinterpretations and misunderstanding have surrounded the use of strong opioids for decades and these are only slowly being resolved”. They add that “until recently, prescribing advice has been varied and sometimes conflicting”.

Professor Mike Bennett, a professor of palliative medicine at the University of Leeds, said on this issue, “Almost half of patients with advanced cancer are under-treated for their pain, largely because clinicians are reluctant to use strong opioids.”

The BBC News coverage cites the murderer Dr Harold Shipman (who used large doses of opioids to murder his victims) as a possible reason for making doctors wary of prescribing strong opioids, although this is not discussed in the NICE guidelines and perhaps distracts from the issue.

Are opioids addictive?

The NICE guidelines say that when offering treatment with strong opioids as pain relief to a patient with advanced and progressive disease, the patient should be asked about concerns such as addiction. Studies show that addiction is a common fear, but it is very rare for people in pain to become addicted to opioids in the same way that recreational heroin users might.

Patients that receive opioids are monitored carefully for any side effects, including the rare problem of addiction, to ensure their medication provides them with the greatest relief possible without diminishing their quality of life. People with concerns about the side effects of opioids and addiction can discuss these with their GP or treating doctor.

*Analysis by NHS Choices. *

NHS Attribution