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GP Dr Anna Saunders speaks to palliative care specialist Dr Katherine Lambert about how to make patients more comfortable

What roles do different pain relief methods have?

Pain is a symptom the majority of palliative care patients are worried about. What advice can you offer for the control of bone pain symptoms in general practice?

I would be guided by the WHO analgesic ladder and use a combination of paracetamol and an NSAID first-line. If necessary, add in an opioid and titrate according to response.

Unfortunately this regime results in multiple medications, especially when you add in laxatives and a proton pump inhibitor which can be difficult for some patients to tolerate. It is necessary to give a thorough explanation for this to aid compliance. Patients are often surprised by the need to use over-the-counter medications when taking something as 'strong' as morphine.

Should we always cover NSAIDs with PPIs?

The patients I commonly see have multiple risk factors for peptic ulceration. It is likely that if the NSAID is effective they will need to continue this indefinitely. My practice is therefore to almost always prescribe a PPI at the same time.

What about the use of radiotherapy?

Radiotherapy for bone pain (usually as a single fraction) can offer excellent pain relief for patients who are well enough to undergo the treatment. It reduces pain relief in 90 per cent of patients and in half of these there is complete relief.

But treatment usually takes a couple of weeks to have an effect and therefore it is not advisable for patients with a very poor prognosis.

What about the role of bisphosphonates?

Bisphosphonates are osteoclastic inhibitors that are used to relieve metastatic bone pain, which persists despite analgesics and radiotherapy. Published data relate mainly to breast cancer and myeloma but benefit is also seen in other cancers. About 50 per cent of patients benefit, typically in seven-14 days and this may last for two to three months.

Many oncology and palliative care units are prescribing intravenous bisphosphonates (pamidronate or zoledronic acid) on a regular basis (every four-six weeks) for patients with known bone metastases for bone pain, particularly when other treatment methods have been exhausted.

Can you explain briefly the key points of using a fentanyl patch over other forms of opioids?

Both WHO and the European Association for Palliative Care recommend morphine as first-line in the treatment of moderate to severe pain. I feel there is a tendency to overuse fentanyl but there are situations where it has certain advantages and could be considered.

These include patients with stable pain who have renal impairment, swallowing difficulties or difficult to manage constipation. It is important to consider that the smallest strength patch of 25mcg/hr is equivalent to 60-100mg morphine over 24 hours and therefore should be used with great caution in opioid naive patients. Another factor to consider is that it takes up to 24 hours to reach effective plasma concentration once the patch is sited and a similar time to eliminate if the patch is removed.

The appropriate breakthrough dose of Oramorph for the different patch strengths needs to be used (refer to the manufacturer's information). When patients enter the terminal phase of their illness my usual practice is to continue changing the patch every three days and to 'top up' their analgesia if necessary using additional analgesia via a syringe driver.

Is there still a shortage of diamorphine in the UK? What should we be using instead?

In the UK diamorphine has been the parenteral opioid of choice over morphine because its greater solubility means larger amounts can be given in very small volumes. But in terms of analgesic efficacy diamorphine has no clinical advantage over morphine by sc or im use.

The Department of Health issued an urgent communication in December 2004 warning of a potential shortfall of diamorphine injection nationwide due to limited supplies available from the manufacturers. Supplies are now at a critically low level and there is no definite date for a resolution of the problem. The advice of my local trust (Bradford Teaching Hospitals Trust) is:

·The oral route and oral morphine should be used wherever possible

·Patients who require continuous subcutaneous opioids should be prescribed morphine instead of diamorphine; a typical starting dose of morphine in opioid naive patients is 10mg/24hr

·24hr requirements of sc morphine should be calculated as 50 per cent of the 24hr oral morphine dose (instead of 33 per cent in the case of diamorphine).

Further information can be obtained via

Do you have a simple conversion chart for changing to and from an opioid?

If in any doubt I always refer to the manufacturer's information for opioid conversions. The BNF also gives helpful guidance on common conversions in its 'Prescribing in Palliative Care' section.

One of the most difficult conversions is from a weak to a strong opioid. Codeine and dihydrocodeine are a 10th as potent as oral morphine, so for a patient taking co-codamol 30/500 two tablets qds an equivalent dose of oral morphine would be 24mg over 24 hours. Tramadol is a fifth as potent as oral morphine.

Is there a role for alternative treatments?

There are a variety of alternative and complementary treatments available (TENS, acupuncture, aromatherapy massage, hypnotherapy etc) and local resources will vary. Many hospices and hospitals now offer these treatments, even for outpatients.

Although there is limited evidence to support their use, uncontrolled trials and patient experience suggest that the positive psychological impact these treatments can offer can be a valuable adjunct to conventional treatment.

How can we treat hiccups and breathlessness?

Hiccups are often difficult to treat. Can you offer a few tips on what we as GPs should think about and try with our patients?

Hiccups can be really distressing, causing fatigue and sleep disturbance. The causes are numerous, including gastric distension, bowel obstruction, uraemia and other biochemical disturbances, CNS disease and diaphragmatic irritation.

There are case reports of a wide variety of drugs being used to treat hiccups. Recently I have found best results using either metoclopramide 10mg qds sc/po or baclofen 5-10mg qds po.

Breathlessness can be very debilitating and I realise that this can be caused by many things. Do you have any suggestions for good symptom control, especially for the anxious patient?

It is important to consider the underlying cause and treat any potential reversible causes such as effusion, infection, bronchospasm, heart failure. General measures include explanation of the likely cause and exploration of patient's fears. Practical measures include access to fresh air or a fan and breathing/relaxation techniques.

Some patients will gain symptomatic benefit from oxygen, although care must be taken with hypercapnia. Evidence shows opioids are effective in palliating breathlessness for patients with advanced disease.

Starting doses in opioid naive patients would be oramorph 2.5mg four-hourly and oramorph 2.5mg prn. For patients already on opioids for pain, breakthrough doses or an increase in their regular dose may be effective.

The evidence for the use of benzodiazepines in breathlessness is conflicting but in clinical practice they certainly have a role, especially where anxiety and panic are features of the breathlessness.

Treating different types of nausea and vomiting

Radiotherapy is useful for treating patients palliatively. But one of my colleagues recently saw a patient with severe radiotherapy-induced dysphagia from mucositis. What advice can you offer?

Reassure the patient that it will settle in time. Good mouth care is essential. Use saline mouthwashes regularly. Food should be soft and of high calorie content with a supplemented diet if necessary. Treat any evidence of oral thrush with fluconazole.

With regard to surface bleeding, eg from recurrent breast cancer, do you have any suggestions on the management that we as GPs and the district nurses can use?

Radiotherapy, embolisation and oral anti-fibrinolytics such as tranexamic acid are all used to control bleeding. Alginate dressings such as Kaltostat or Sorbsan can be used, although care must be taken on removal of the dressings to prevent rebleeding. Adrenaline 1:1000 applied on a gauze pad with light pressure for 10 minutes is an alternative for more profuse bleeding.

Do you have any advice on how to manage terminal agitation more effectively to ensure our patients can stay at home?

Before starting drug treatment, check for common underlying or exacerbating factors like pain, hypoxia, constipation and urinary retention. When sedation is required, the most commonly prescribed drug is midazolam. Starting doses would be 2.5-5mg sc prn. If more than two doses have been necessary, consider midazolam via a syringe driver (10-60mg over 24 hours).

Useful website

This website provides excellent comprehensive information for health professionals about the use of drugs in palliative care. It highlights drugs given for unlicensed indications or by unlicensed routes, and the administration of multiple drugs by subcutaneous infusion.

Anna Saunders is a GP in West SussexKatherine Lambert is specialist registrar in palliative care medicine, Bradford Royal InfirmaryThe authors are grateful for input from Dr Belinda Batten, consultant in palliative care, Bradford Royal Infirmary

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