UK regulator backs first-line opioids
MedWire News: The UK health regulator has said that opioids should be considered a first-line option for patients receiving palliative care for chronic or incurable diseases.
In a new clinical guideline, the National Institute for Health and Clinical Excellence (NICE) states that strong opioids are the only effective analgesic for some patients and notes that good communication between healthcare professionals and patients is the key to safe and consistent prescribing of these drugs.
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," he added.
"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 contains recommendations for general practitioners and other nonspecialists on how to initiate strong opioids, optimizing the dose for maintainance therapy, alternatives to oral opioids (transdermal patches, subcutaneous delivery), managing breakthrough pain, and dealing with common side effects (nausea, drowsiness, constipation).
It also contains detailed advice on communicating with patients and suggests that when offering patients pain treatment with strong opioids, clinicians should discuss concerns such as addiction, tolerance, and side effects.
For opioid maintenance therapy in patients with advanced and progressive disease, NICE recommends sustained-release morphine in the first instance.
Transdermal patch formulations should be used only in patients for patients in whom oral opioids are unsuitable; the guideline urges care when calculating "opioid equivalence" for transdermal patches, noting that a transdermal fentanyl 12 mcg patch equates to approximately 45 mg/day of oral morphine while a transdermal buprenorphine 20 mcg patch equates to approximately 30 mg/day.
For patients with breakthrough pain while on maintenance oral morphine, the guideline recommends offering oral immediate-release morphine and advises against the use of fast-acting fentanyl. If pain remains inadequately controlled despite optimal first-line maintenance treatment, it recommends reviewing the analgesic strategy and seeking specialist advice.
Damien Longson, Chair of the NICE Guideline Development Group, said: "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."
A care pathway and other tools to help with guideline implementation are also available.
By Joanna Lyford