By the clock

• Cancer pain is often continuous, use regular analgesia at appropriate dose intervals not when required

By the mouth

• The oral route is preferred for all steps of the analgesic ladder

By the ladder (see below)

• Although there is no maximum dose for strong opioids, most patients require doses less than 180mg/24hours oral morphine, or a 50 micrograms/hour fentanyl transdermal patch.
• If pain is still a problem with high doses of morphine (e.g. greater than 200mg/24hrs), or severe side effects occur, please seek specialist advice.

Step 1

• Regular Paracetamol 1g six hourly (or appropriate lower dose)
• Add in NSAID such as naproxen (maximum 500mg 12 hourly) or ibuprofen (maximum 800mg eight hourly) unless contraindicated. Consider gastro-protection. Stop NSAID if not effective.
• Adjuvant analgesic may be added e.g. amitriptyline

Pain persisting or increasing: Add in weak opioid as a combination drug if NSAID/paracetamol not sufficient

Step 2

• Co-codamol 8/500 two tablets six hourly when required, or
• Co-dydramol 10/500 two tablets six hourly when required, or
• Co-codamol 30/500 two tablets six hourly when required
• Adjuvant analgesic may be added e.g. amitriptyline

Pain persisting or increasing: Prescribe one drug at a time in step 2 to achieve effective analgesia, stepping up as necessary

Step 3

• Non-opioid analgesia plus opioid for moderate to severe pain, morphine oxycodone or fentanyl patches
• Adjuvant analgesic may be added e.g. amitriptyline

It may be appropriate to move straight from step 1 to step 3 of the ladder in some cases. Please seek advice if unsure.

Side effects of Opioids

Common:

• Constipation should be anticipated and treated proactively in all patients on weak or strong opioids. Regular laxatives should be commenced at the same time as the opioid and may need to be titrated as appropriate. (see constipation section for information)
• Sedation may occur with the first few doses, but then often it lessens. Give appropriate advice regarding driving when taking strong opioids or any medication that may cause sedation. Please refer to the driving section below.
• Nausea is a common problem during the first few days of treatment. Consider prescribing an antiemetic if appropriate. (see nausea and vomiting section for information)

Also recognised are:

• Dry mouth
• Itching
• Myoclonic jerks
• Sweating
• Hallucinations
• Bronchospasm (rare)

Opioid toxicity

This may present with visual hallucinations, vivid dreams or excessive drowsiness. Myoclonic jerks may also be noticed. Reduction of opioid dose or changing to an alternative opioid may resolve these effects.

When used appropriately opioids very rarely cause respiratory depression.

Opioid-induced hyperalgesia

Escalating doses of opioids occasionally induce escalation of pain, particularly at high doses. This phenomenon is known as opioid-induced hyperalgesia. Seek specialist advice if you are concerned about this.

Opioid switching

Generally, switching from morphine to another strong opioid is considered in an attempt to improve analgesia and/or reduce unwanted side-effects. Before opioid switching consider other options e.g. using an adjuvant analgesic or treating side-effects

A guide to equivalent doses of opioid drugs, hosted on the Rowcroft Hospice website and often used in palliative care, has been developed by local specialists across the region. Please note this is not a definitive set of equivalences. Drug conversions can be challenging, it is recommended that conversion calculations are double checked with a colleague. If in any doubt seek specialist palliative care advice.

Please be aware that supplies of diamorphine 5mg and 10mg injection will be unpredictable for the foreseeable future (DHSC, March 2020). For patients requiring subcutaneous pain relief, morphine is the first line opioid if clinically appropriate. As morphine is not as soluble as diamorphine and the maximum strength available is 30mg/1ml, this may be an issue for patients requiring high doses of subcutaneous morphine. If volume of medication in a syringe driver is a concern, please seek advice from the palliative care team.

Do not start new patients on diamorphine 5mg and 10mg injection, and review patients currently receiving these injections. See section 4.7.2 Opioid analgesics for a list of preparations

See Management of opioids - Rotating/switching opioids for further guidance.

Morphine, diamorphine and oxycodone and their active metabolites accumulate in renal failure, causing sedation, myoclonic jerks, hallucinations and respiratory depression.

It may be necessary to:

• use much lower doses of usual opioid
• to increase dose interval
• to use immediate release opioid preparations rather than modified release preparations
• to switch to a more renal friendly opioid
  • St Luke's Hospice: Guidance on the use of opioids in renal impairment
  • Rowcroft Hospice

If in doubt, consult the specialist palliative care team for advice.

Many centrally acting drugs have the potential to influence driving performance. Doctors have a duty of care to inform patients of this risk and advise them accordingly.

Driving performance does not appear to be affected by stable doses of appropriately titrated strong opioids.

Advise the patient not to drive after initiating opioids or after titration of opioids until they have been on a settled dose for about a week and have no undue side-effects.

They should not drive after taking a when required dose of strong opioid.

It is the patient's responsibility that they are in a fit state to drive whilst talking prescribed opioids

DVLA: Drug and driving information

Patient information leaflet on Drugs and driving

Breakthrough pains are transitory flare ups of pain against a background of otherwise well controlled pain.

Ensure patients have access to immediate release opioid (e.g. Morphine sulphate oral solution) for episodes of breakthrough pain. Prescribe a dose up to 1/6 of total 24 hour oral morphine dose.

If more than 3 doses of breakthrough pain relief are regularly needed over 24 hours it may suggest poorly controlled pain and a review of the maintenance analgesic regime may be required. Dose increases should not exceed 1/3-1/2 of total daily dose.

When the dose of m/r morphine is increased, the breakthrough dose of immediate release morphine should be increased proportionately.

Morphine

For most patients morphine is the opioid of choice.

Do not start new patients on diamorphine 5mg or 10mg injections; supplies will be unpredictable for the foreseeable future (DSHC, March 2020). If parenteral administration is required, for most patients morphine SC is the first line opioid.

Initiation and titration of morphine

• Patients can be started on either an immediate release or a modified release (m/r) formulation
• If using immediate release morphine, start at a dose of 5-10mg every 4 hours.
• In the elderly or those with renal impairment smaller doses and longer dose intervals may be required e.g. 2.5mg 6-8 hourly (see above for the use of opioids in renal failure)
• Increase the dose required by titrating against pain, usually increased by 30-50% every 2-3 days or sooner if necessary.
• A log of treatment kept by patients and carers is helpful in titration
• If pain appears to respond to opioids, establish the patient on regular m/r morphine. To convert to m/r morphine add up the total amount taken by the patient in the last 24 hours, divide by 2 and this gives the 12 hourly dose.
• If initiating the patient on m/r morphine the starting dose will depend upon whether they are opioid naïve (usual starting dose 10mg 12 hourly but may need to be 5mg if the patient is elderly or frail). If converting from step 2 of the analgesic ladder (starting dose likely to be in the order of 15mg 12 hourly).
• Provide immediate release morphine when required. If necessary increase the dose of m/r morphine every 2-3 days until there is adequate relief throughout each 12 hour period, guided by when required use.

Most patients will require less than 180mg morphine per 24 hours to achieve pain control.

A patient should not normally be prescribed more than one modified release opioid at a time.

Available preparations

• See 4.7.2 Opioid analgesics for information on preparations

Relative doses of opioids:

• Morphine 20mg PO = Morphine 10mg SC (2:1 conversion ratio)
• Please be aware that supplies of diamorphine 5mg and 10mg injection will be unpredictable for the foreseeable future (DHSC, March 2020). For patients requiring subcutaneous pain relief, morphine is the first line opioid if clinically appropriate. As morphine is not as soluble as diamorphine and the maximum strength available is 30mg/1ml, this may be an issue for patients requiring high doses of subcutaneous morphine. If the volume of medication in the syringe driver is a concern, please seek advice from the palliative care team.

Guide to equivalent doses for opioid drugs

• A guide to equivalent doses of opioid drugs, hosted on the Rowcroft Hospice website and often used in palliative care, has been developed by local specialists across the region. Please note this is not a definitive set of equivalences. Drug conversions can be challenging, it is recommended that conversion calculations are doublechecked with a colleague. If in any doubt seek advice from the specialist palliative care team.
• Do not start new patients on diamorphine 5mg and 10mg injection, and review patients currently receiving these injections. Supplies of these injections will be unpredictable for the foreseeable future (DSHC, March 2020). See section 4.7.2 Opioid analgesics for a list of preparations

See also Care of the dying person

See also Management of opioids - Rotating/switching opioids

Fentanyl (Opiodur)

Prescribers are reminded to prescribe transdermal fentanyl by brand (Opiodur) to ensure continuity and avoid confusion.

There are two different conversions for oral morphine to transdermal fentanyl depending on the nature of the change and the individual patient:

• Adult patients who are on a stable, and well-tolerated opioid regimen:
  • oral morphine 60mg/24 hours is approximately equivalent to 25 micrograms/hour transdermal fentanyl
• Adult patients who are less clinically stable:
  • oral morphine 90mg/24 hours is approximately equivalent to 25 micrograms/hour transdermal fentanyl

The decision regarding which conversion to use should be based on patient specific factors, the level of patient monitoring which can be offered and the clinical setting.

Due to its slow onset (approximately 24 hours) and long period of action (72 hours), transdermal fentanyl is not suitable for acute pain where rapid dose titration is required.

It is also inappropriate for use in patients whose pain is unstable because of inflexibility in terms of rapid titration up or down of opioid dose.

Fentanyl can be considered as an alternative to morphine for patients:

• whose opioid-responsive pain is stable
• with renal failure
• who are unable to tolerate morphine
• who are unable to take oral medication e.g. dysphagia, vomiting
• in whom drug compliance needs to be improved
• with constipation despite optimising aperient regimes

Available preparations

• See 4.7.2 Opioid analgesics for information on preparations

Cautions

• patients on low doses of morphine less than 30mg/24 hours or none
• the rate of absorption of fentanyl may be increased if the skin under the patch becomes vasodilated e.g. in febrile patients, when using saunas, hot tubs or electric blankets
• drug interactions can increase fentanyl levels
• awareness that fentanyl is a strong opioid analgesic and equivalent morphine doses may be higher than anticipated

Side effects

• fentanyl causes the same side effects as morphine, however, constipation may be less severe with transdermal fentanyl

Refer to prescribing notes in section 4.7.2 Opioid analgesics for further prescribing notes and MHRA Drug Safety Updates.

Initial dose

• convert from the oral morphine dose according to the equivalence dosages
• for those patients requiring high doses, please seek advice from the Specialist Palliative Care Teams

Switching to fentanyl patches

Patients converting from:

• 4 hourly immediate release morphine
  • continue to give morphine every 4 hours for the first 12 hours after applying the patch
• 12 hourly m/r morphine
  • apply the first fentanyl patch at the same time as taking the final 12 hour morphine tablet
• 24 hourly m/r morphine
  • apply the first fentanyl patch 12 hours after taking the final 24 hourly morphine capsule
• Syringe Pump
  • apply the first fentanyl patch, and then use clinical judgement to decide when to switch off the syringe pump
  • base your decision on the patient's general condition, their pain and the half-life of the analgesic in the syringe pump
  • Palliative Care Formulary (fifth edition, 2014) recommends the following:
    • for morphine syringe pump, continue the infusion unchanged for 8-12 hours after applying the patch and then discontinue
    • for fentanyl syringe pump, continue the infusion unchanged for 6 hours after applying the patch, then discontinue
  • if in doubt, switch off the syringe pump 6-8 hours after applying the patch

Warn the patient that they might experience more breakthrough pain than usual in the first 1 to 3 days. An immediate release opioid preparation should always be available for breakthrough pain (up to 1/6 of the equivalent 24 hour oral morphine dose).

The dose of the fentanyl patch should not be changed within the first 2 days of the first application

Titrate the dose up in 12 or 25 microgram/hour steps if needed when the next patch change is due, according to use of breakthrough medication.

Apply the patch to dry, non-irritated, non-irradiated, non-hairy skin on the torso or upper arm, removing after 72 hours and positioning replacement patch on a different area, avoid using the same area for 7 days. Replace patches at the same time of day, every 3 days.

Laxatives may need to be reduced.

Discontinuing transdermal fentanyl patches

Remember, on removal a depot remains in the skin for 24 hours, falling by 50% by 17 hours.

Therefore, in a patient whose pain is controlled either…..

• Change to modified release morphine:
  • remove patch 12 hours before the first modified release morphine dose
  • ensure adequate dose of immediate release morphine is available for breakthrough pain
  OR

• Change to subcutaneous morphine infusion:
  • in the last few days of life the patch is usually continued alongside a syringe pump if needed. Seek advice if needed
  • ensure adequate dose of morphine is available for breakthrough pain (up to 1/6 of the equivalent 24 hour oral morphine dose).
  • when calculating doses refer to the guide to equivalent doses for opioid drugs or contact the specialist palliative care team. If you are in any doubt about these calculations, ask for specialist advice
  • if it is deemed necessary to discontinue the patch, it should be removed 12 hours before setting up the syringe pump

See 4.7.2 Opioid analgesics for list of preparations.

Effentora buccal tablets and Abstral sublingual tablets are the formulary choice products for transmucosal fentanyl. These products require careful titration and are relatively expensive compared with alternatives. The doses of Effentora and Abstral are not interchangeable.

Following national guidance from NHS England, Effentora and Abstral should only be used in patients undergoing palliative care treatment and where the recommendation to use immediate release fentanyl in line with NICE guidance, has been made by a multi-disciplinary team and/or other healthcare professional with a recognised specialism in palliative care. Do not prescribe for patients with non-cancer pain.

Effentora and Abstral are indicated for the treatment of breakthrough pain in adults receiving maintenance opioid therapy for chronic cancer pain. Breakthrough pain is a transient exacerbation of otherwise controlled chronic background pain. Patients receiving maintenance opioid therapy are those who are taking at least 60 mg of oral morphine daily, at least 25 micrograms of transdermal fentanyl per hour, at least 30 mg of oxycodone daily, or an equianalgesic dose of another opioid for a week or longer.

Transmucosal fentanyl preparations have a faster onset of action and shorter duration of effect compared to other opioid analgesic preparations and may be useful for the management of incident pain, in the following situations:

• For the minority of patients with breakthrough pain that fail immediate release morphine or oxycodone.
• For patients who have acute, severe pain which is predictable but not long lasting e.g. dressing changes, painful bone metastases affecting mobilising, transferring or personal care

Assessment of pain prior to initiation

Seek specialist palliative care advice before initiating transmucosal fentanyl to ensure full assessment of pain.

Effective control of chronic pain with around the clock opioids should be achieved prior to commencing treatment with transmucosal fentanyl. Do not use in opioid non-tolerant/opioid naïve patients – all patients must be on background opioid treatment.

1. Assess pain control: Is persistent malignant pain controlled?
   1. Yes - But episodes of breakthrough pain not controlled – progress to step 2
   2. No - Further titration of around the clock background opioids e.g. morphine sulfate m/r, oxycodone m/r, fentanyl patch
2. Assess and diagnose breakthrough pain: Flare of severe pain, sudden onset and short duration, on a background of controlled pain. Pattern, cause, character, location - does it occur when there is activity or nursing interventions?
3. Trial of morphine oral solution or oxycodone: Prescribe a 'when required' dose of morphine oral solution or immediate release oxycodone (1/6 of the total 24hour background dose)
4. Success with immediate release morphine or oxycodone: Continue with this, keeping under assessment for side effects and speed of onset.
5. Unsuccessful with immediate release morphine or oxycodone - Onset of pain relief is too slow, persistent drowsy side effects due to long length of action, worsening constipation. Patient in pain due to lack of concordance with morphine oral solution or oxycodone. Offer transmucosal fentanyl.

Starting transmucosal fentanyl

Constant reassessment is needed for accurate symptom control. All patients receiving transmucosal fentanyl prescriptions should be reviewed weekly.

All prescriptions must be written by brand as Effentora® or Abstral® and not as generic fentanyl. This will enable the correct formulation to be dispensed.

Patients experiencing xerostomia are advised to drink water to moisten the buccal mucosa and cavity prior to administration of Effentora or Abstral.

Effentora and Abstral require dose titration to determine the optimal dose. This is outlined in brief below; consult manufacturer's summary of product characteristics (SPC) for further details. There is no direct conversion from other opioids and the correct dose must be established by titration. The doses of Effentora and Abstral are not interchangeable. If a patient has previously used another transmucosal fentanyl preparation the correct dose must be re-titrated - stop current transmucosal fentanyl and start replacement transmucosal fentanyl at next breakthrough pain episode.

Effentora

Initiating Effentora fentanyl buccal tablets (100 micrograms, 200 micrograms, 400 micrograms, 600 micrograms, 800 micrograms):

• Initiate treatment with Effentora 100 micrograms. If successful pain control, prescribe this dose.
• If pain is not controlled after 30 minutes, a second Effentora tablet of the same strength should be given (See alternative unlicensed regimen below). Pain control must be assessed.
• Patients should wait at least 4 hours before treating another breakthrough pain episode with transmucosal fentanyl.
• If the breakthrough pain episode required the use of the second tablet, an increase in dose to the next strength should be given at the next episode.
• Continue this routine until the correct dose is found.
• Doses above 800 micrograms were not evaluated in clinical trials.
• Once titrated to an effective dose, patients should use only one tablet, of the correct dose, per breakthrough pain episode

Local specialists have indicated that the licensed titration regimen above may be too rapid for some patients. The regimen below is unlicensed and a combination of strengths may need to be prescribed. Specialist advice should be sought; the following guidance may be appropriate (taken from Scottish Palliative Care Guidelines):

Abstral

Initiating Abstral fentanyl sublingual tablets (100 micrograms, 200 micrograms, 300 micrograms, 400 micrograms, 600 micrograms, 800 micrograms):

• Initiate treatment with Abstral 100 micrograms. If successful pain control, prescribe this dose.
• If pain is not controlled after 15-30 minutes, a second Abstral® 100 microgram tablet should be given. Pain control must be assessed.
• Patients should wait at least 2 hours before treating another breakthrough pain episode with transmucosal fentanyl.
• If the episode required the use of the second tablet, an increase in dose to the next strength should be given at the next episode. In practice, patients may be offered a further trial at the lower strength before increasing to the next strength, to evaluate more accurately (unlicensed, following local specialist advice).
• The dose strength for the supplemental (second) sublingual tablet should be increased from 100 to 200 micrograms at doses of 400 micrograms and higher as per table below:

• Continue this routine until the correct dose is found.
• Doses above 800 micrograms were not evaluated in clinical trials.
• Once titrated to an effective dose, patients should use only one tablet, of the correct dose, per breakthrough pain episode

Dose re-adjustment

When patients require more than one dose for several consecutive episodes, having been previously stable:

• If more than 4 breakthrough pain episodes occur in 24 hours review the long-acting background opioid medication
• If the patient feels very dizzy or very sleepy before the tablet is completely dissolved, they should rinse their mouth with water and spit the remaining pieces of the tablet into a sink or toilet right away. The next dose should be reduced.
• If pain control is not achieved at the maximum dose for the product an alternative treatment must be found.

Buprenorphine (Sevodyne)

Buprenorphine may occasionally be useful for patients who would benefit from a transdermal analgesic but whose opioid dose requirements are too low to consider a fentanyl patch.

The indications are otherwise similar to those for fentanyl, including the recommendation for use in stable pain only.

Buprenorphine is generally safe to use in renal impairment. It is approximately 100 times more potent than morphine. We recommend seeking specialist advice regarding which dose to use.

Formulary preparations:

• See 4.7.2 Opioid analgesics for information on preparations

To avoid confusion, please be aware that transdermal buprenorphine patches are available in two formulations and note the different patch change intervals for each:

• Buprenorphine 5, 10, 15 and 20 microgram/hour 7-day patches (Sevodyne) - formulary choice
• Buprenorphine 35, 52.5, 70 microgram/hour 3-day (Hapoctasin) or 4-day patches (Transtec) - non-formulary

The maximum authorised dose is two 70 microgram/hour patches.

Oxycodone

• a strong opioid with similar properties to morphine.
• often considered the 2nd line oral opioid when patients fail to respond to, or have unacceptable side-effects with morphine. In some patients it is more effective and has a more favourable side-effect profile.

The oral dose conversion ratio for morphine and oxycodone is approximately 1.5:1 but safe practice is to recommend a clinical ratio of 2:1.

When converting a patient to oxycodone, the dose of morphine (either orally or parenterally) should be halved for an equivalent dose via the same route:

• e.g. oral morphine 20mg = oxycodone 10mg,
• e.g. subcutaneous morphine 10mg = oxycodone 5mg

Relative doses of opioids:

• Guide to equivalent doses for opioid drugs
• See also Care of the dying person

Parenteral oxycodone is equivalent to half the dose of oral oxycodone

• e.g. oxycodone for injection 5mg subcutaneous is equivalent to oral oxycodone 10mg

Like morphine, oxycodone is available in both m/r and immediate release formulations.

Available preparations

• See 4.7.2 Opioid analgesics for information on preparations
• Prescribe oral preparations by brand. Oral oxycodone modified release preparations are available in 12-hourly and 24-hourly (non-formulary) formulations. Oral oxycodone immediate release preparations are available as capsules and tablets (non-formulary) formulations. Brand-name prescribing is recommended to reduce the risk of confusion and error in dispensing and administration.

Oxycodone with naloxone (Targinact)

Targinact is seldom used in Specialist Palliative Care. It may be useful in some palliative care patients with severe pain requiring opioid analgesia but experiencing constipation where laxative treatment has failed.

It should not to be used in patients with liver failure or those at risk of liver failure e.g. patients with liver metastases because of the need for 1st pass metabolism of naloxone.

Available preparations

• See 4.7.2 Opioid analgesics for information on preparations

Tapentadol

• a centrally acting analgesic with a dual mode of action (it acts at opioid receptors and as an inhibitor of synaptic re-uptake of noradrenaline).
• MHRA Drug Safety Update (January 2019): Tapentadol (Palexia): risk of seizuresand reports of serotonin syndrome when co-administered with other medicines

Its use is currently best restricted to patients who fail to get satisfactory analgesia from conventional strong opioids +/- adjuvant medications.

Please seek specialist advice.

An adjuvant analgesic is a drug primarily used for other indications but which can provide pain relief in certain situations. They have also been called co-analgesics and can be used in combination with drugs at all steps of the analgesic ladder.

The information provided in the sections below is not all-inclusive and further specialist advice should be sought if necessary.

Patients at risk of NSAID induced gastro duodenal ulceration, and those taking both steroids and NSAIDs together, should be considered for gastro-protection. Please refer to section 10.1 Drugs used in rheumatic diseases and gout and Prescribing non-steroidal anti-inflammatory drugs (NSAIDs)

For some palliative care patients, it may be appropriate to consider celecoxib as an alternative to a traditional NSAID

See Neuropathic pain

In palliative care, the starting doses for gabapentin and pregabalin will generally be lower and dose titration more cautious:

Gabapentin:

• start with 300mg orally at night. If necessary increase slowly by 300mg/24hr every 2-3 days up to 600mg three times a day
  • in elderly and frail, slower titration is advisable e.g. 100mg at night, increased if necessary by 100mg/24hrs every 2-3 days
  • maximum recommended dose 1,200mg 8 hourly

Pregabalin:

• 25mg–300mg twice a day. Begin at 75mg twice a day and, if necessary, titrate up at intervals of 3-7 days.
  • in elderly and frail, start with 25-50mg twice a day and titrate up more cautiously.
  • maximum recommended dose 300mg twice a day

A dose reduction for gabapentin and pregabalin is required in patients with renal impairment, if in doubt, seek specialist advice.

Dose adjustments for gabapentin in renal impairment

Dose adjustment for pregabalin in renal impairment

*37.5mg capsules are not available, necessitating 8 hourly regimen. Please revert to usual 12 hourly dose when titrating dose upwards

Stopping gabapentin and pregabalin

• To avoid precipitating pain or seizures, withdraw gradually over several weeks.

Other drug treatments

Corticosteroids

• Oral dexamethasone 6-8mg in single or divided doses (last dose no later than 2pm to avoid sleep disturbance)

Lidocaine 700mg (5% w/w) medicated plasters may be helpful in patients with focal allodynia.

For radiculopathy (nerve root pain) also consider

Transcutaneous nerve stimulation (TENS)

Nerve block/interventional approach (involve the Chronic Pain Team)

• NSAIDs, be aware of risk factors associated with NSAIDs (e.g. renal impairment, cardiac complications, and GI bleed), renal function may need monitoring
• consider oncology review e.g. radiotherapy, bisphosphonates
• consider neuropathic agents
• consider corticosteroids

Corticosteroids

• Dexamethasone at least 16mg orally in 2 divided doses (last dose no later than 2pm to avoid sleep disturbance)

Co-codamol 30/500

• two tablets four times a day

Consider morphine

Consider radiotherapy

Corticosteroids

• Dexamethasone 4-8mg orally in single or divided doses (last dose no later than 2pm to avoid sleep disturbance)

NSAIDs

Diazepam

• 2mg-10mg orally daily

Baclofen

• 5mg-10mg orally 12 – 8 hourly (for spasticity, the effective dose is generally 20mg or less 8 hourly)

Please refer to: Malignant gastro-intestinal obstruction

• Poorly responsive to opioids
• Avoid stimulant laxatives and prokinetic antiemetics
• Consider antispasmodic e.g. hyoscine butylbromide

• Prevent and treat constipation
• Opioid analgesia may be helpful
• NSAID
• Consider radiotherapy
• Adjuvant analgesics as for neuropathic pain e.g. tricyclic antidepressants, anticonvulsants
• Corticosteroids
• Nifedipine 10mg capsules 12 hourly then change to 20mg LA preparation once daily
• Consider nerve block/interventional approach (involve the Chronic Pain Team)