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NICE guideline to standardise opioid use in palliative care and address patients' concerns

A new clinical guideline published today (23 May) by the National Institute for Health and Care Excellence (NICE), will help ensure safe and consistent prescribing of opioids as a first-line treatment option to relieve pain for patients receiving palliative care for chronic or incurable illnesses.

Each year, around 300,000 people are diagnosed with cancer in the UK and it is thought another 900,000 people have heart failure. Others live with chronic illnesses such as kidney or respiratory conditions, or neurodegenerative conditions like motor neurone disease. For many of these people, strong opioids will be the only adequate source of pain relief. However, evidence suggests that pain caused by advanced disease remains under-treated despite a range of opioids being recommended for use in the NHS. Many patients also worry about the long-term use of opioids, their side-effects and the possibility of becoming addicted.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Many people with chronic or advanced conditions will experience a high level of pain which can only be treated by opioids such as morphine as weaker forms of pain relief will no longer be effective. However, we understand that patients can be anxious about using these medicines for a number of reasons. Likewise, healthcare professionals may not always be sure about when to prescribe certain types of opioids.

"The new guideline aims to address all those fears and provide clear advice to the NHS to ensure a consistent approach to treatment and ultimately help to drive up standards of care."

The guideline makes recommendations in a number of key areas, including:

  • Communication:When offering a patient pain treatment with strong opioids, ask them about concerns such as: addiction, tolerance, side effects, fears that treatment implies the final stages of life. Offer patients access to frequent review of pain control and side effects and information on who to contact out of hours, particularly during initiation of treatment.
  • Starting treatment: When starting treatment with strong opioids, offer patients with advanced and progressive disease regular oral sustained-release or immediate-release preparations (depending on patient preference and clinical presentation), with rescue doses of oral immediate-release preparations for breakthrough pain.
  • First-line maintenance therapy: Offer oral sustained-release morphine as first-line maintenance therapy to patients with advanced and progressive disease who require strong opioids. If pain remains uncontrolled despite optimising first-line therapy, review analgesic strategy and consider seeking specialist advice.

Dr Damien Longson, Chair of the Guideline Development Group (GDG) for this guideline, said: "Because opioids are powerful medicines people worry they can become addicted, particularly if opioids are prescribed over an extended period of time. This guideline puts a strong emphasis on good communication between healthcare professionals and patients, which is key to ensuring any worries or uncertainties are addressed with timely and accurate information. This will help the patient to feel content in following what has been prescribed and therefore potentially improving their pain control and reducing any associated side effects."

Professor Mike Bennett, St Gemma's Professor of Palliative Medicine at the University of Leeds and GDG member, said: "Until now, there has been little guidance regarding the safe prescribing of opioids. Despite increased availability of these medicines, pain from advanced conditions remains under-treated. This can be due to a variety of reasons such as fears over side-effects or confusion over which opioid treatment would work best. This guideline gives clear recommendations and should instigate a real clinical change in the way opioids are prescribed."

Opioids are also associated with side-effects such as constipation, nausea and drowsiness. The new guideline acknowledges this and makes recommendations for healthcare professionals to help inform patients and treat these adverse effects appropriately. These include:

  • Informing patients that constipation affects nearly all patients receiving strong opioid treatment and prescribing laxative treatment (to be taken regularly at an effective dose) for all patients initiating strong opioids.
  • Advising patients that nausea, or mild drowsiness or impaired concentration may occur when starting opioid therapy or at dose increase, but that these effects are most likely to be transient.

Dr Lindsay Smith, a Somerset GP and member of the GDG, said: "Primary care professionals have an increasingly important role to play in the prescribing of medicines for people who have chronic or advanced conditions and require strong pain relief. Many people with long-term health conditions continue to live at home and will therefore depend on the knowledge and advice of their GP. This guideline will ensure opioids are prescribed appropriately and safely across primary and secondary care. I hope this consistency will be welcomed not just by GPs but also by other doctors involved in initiating strong opioids as a pain-reliever for patients with long-term or advanced illnesses."

Natalie Laine, whose husband Mark passed away in 2009 from motor neurone disease, also helped to develop the guideline. She said: "Having had to watch Mark deal with the impact, complications and fears of opioid use, I was keen to try and help produce a guideline that would give the best possible care to other patients with incurable illnesses, whatever they may be suffering from. These people are sadly facing the scariest time of their lives and correct opioid use can make all the difference in minimising pain and helping them to feel comfortable. I feel passionately that there should be national guidance to deal with all issues to do with opioid use and I'm so pleased that I've been able to contribute to its development. My hope now is that thisguideline will be used by doctors and nurses looking after patients with chronic or incurable conditions who need strong pain relief."

Ends

Notes to Editors

About the clinical guideline

  • The new guideline, Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults, will be available on the NICE website from Wednesday 23 May 2012 at http://www.nice.org.uk/CG140. Please contact the NICE press office for an embargoed copy of the guidance.
  • A variety of strong opioids are licensed in the UK but only a relatively small number are used for pain relief in palliative care. This guideline has therefore looked at the following drugs: buprenorphine, diamorphine, fentanyl, morphine and oxycodone.
  • According to expert opinion, it is unlikely the NHS will incur significant costs in implementing this guideline. By following its recommendations (and depending on need in local areas), it is expected that the cost to the NHS will remain the same or may even lead to a small saving. An increase in the prescribing of strong opioids as a result of this guidance is not anticipated, rather a change in which opioids are used first.
  • A range of 'tools' have been developed alongside this guideline to help NHS bodies implement the recommendations. These tools include a slide set to help inform staff, a costing report for commissioners and an audit tool. They can be downloaded from the NICE website: http://www.nice.org.uk
  • NICE also has a Field Team which works directly with organisations and local NHS bodies to help them implement NICE guidance.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

This page was last updated: 22 May 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.