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NICE offers guidance on opioids

Patients need explanation of side-effects before they start treatment

Louise Prime

Wednesday, 23 May 2012

People with advanced disease are suffering unnecessarily because of under-treatment with opioids in the NHS, the National Institute for Health and Clinical Excellence said today. In its latest clinical guideline, NICE said that strong opioids are the only effective treatment for severe pain for many patients needing palliative care, but that doctors must address patients’ concerns about addiction and side-effects.

NICE says that its guidance should “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”.

It acknowledges that adverse effects such as constipation, nausea and drowsiness often occur with strong opioids, but makes recommendations regarding how healthcare professionals can inform patients and appropriately treat these problems. These include prescribing laxatives concurrently, and advising patients that if they experience nausea, or mild drowsiness or impaired concentration at the start of opioid therapy or when they increase the dose, this will probably be transient.

The guideline recommends that:

  • When offering a patient strong opioids, ask about concerns such as addiction, tolerance, side-effects and fears that treatment implies the final stages of life. Offer them access to frequent review of pain control and side-effects, and information on whom to contact out of hours, particularly during initiation of 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.
  • 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.

Somerset GP and guideline development group (GDG) member Dr Lindsay Smith 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.”

GDG member Professor Mike Bennett, St Gemma’s Professor of Palliative Medicine at the University of Leeds, said: “The biggest barrier to good pain control for patients with advanced cancer is not the lack of good drugs, but inadequate support and advice, poor communication, lack of pain monitoring, and a lack of access to painkillers.

“By working with patients and their carers to tackle each of these issues, we hope to minimise patients’ distress from pain and reduce the number of avoidable hospital admissions.”

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