Prescribing Notes for Palliative care and Persistent Pain in Older Patients

N.B. If the patient's pain remains unresolved despite using the treatment guidance below, or local guidelines, refer to the appropriate team for further advice.

Step 1 - Mild Pain

Use oral paracetamol (not IV) or NSAID (if not contraindicated) +/- other adjuvant (see below).

Paracetamol oral: 1g four times daily (max dose). Consider dose reduction in patients with low body weight (<50kg), renal impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). An example is: paracetamol oral 500mg four times daily.

In patients with hepatocellular insufficiency, a dose reduction of the oral preparation should be determined on a case by case basis with senior medical input. N.B. Patients with chronic liver failure may require a further dose adjustment (7.5mg/kg/dose, max 30mg/kg/day).

Step 2 - Weak Opioid e.g. co-codamol

Weak opioid + paracetamol (dose as above) or NSAID +/- other adjuvant

Co-codamol* oral 30/500mg 1 - 2 tablets four times daily (max 8 tablets in 24 hours) or

Codeine oral 30 - 60mg four times daily (max 240mg/day) or

Dihydrocodeine oral 30mg four times daily (max 120mg/day).

Note: dihydrocodeine 60mg will provide little additional analgesia but more pronounced side effects.

General Notes

• *Co-codamol contains paracetamol. Reduce dose as appropriate, see paracetamol dosing guidance above.
• Older patients are more likely to experience side effects e.g. confusion, constipation. Carry out early review of response to analgesia. Where possible co-prescribe a laxative (see Management of Constipation).
• If step 2 analgesics are not tolerated, reassess pain and consider moving to step 3.

Step 3 - Moderate to severe pain

Opioid (morphine first-line) + paracetamol (dose as above) or NSAID +/- other adjuvant. N.B. If renal impairment (eGFR <60ml/minute/1.73m²) seek palliative care advice or refer to www.palliativecareguidelines.scot.nhs.uk, pain section then select 'Choosing and Changing Opioids'

General Notes

• Stop any Step 2 opioid (conversion: codeine / dihydrocodeine 240mg/24 hours ≈ morphine oral 24mg/24 hours).
• If commencing with immediate release oral morphine give 5mg every 4 hours and as required for breakthrough pain. Use lower doses and increase slowly if patient is frail, elderly or has renal impairment. Convert to modified release morphine when stable by dividing total daily dose of immediate release morphine by 2 and prescribe the dose as oral morphine modified release 12 hourly.
• If starting patient with modified release oral morphine give 10 - 15mg twice a day and immediate release morphine 5mg as required for breakthrough pain. Use lower doses and increase slowly if patient is frail, elderly or has renal impairment.
• Dose titration: increase regular oral morphine dose each day by around 30% (or according to the breakthrough doses used) until pain is controlled or side effects develop. Also increase laxative dose as needed (see Management of Constipation for choice).
• Breakthrough pain - prescribe immediate release morphine at 1/6th of the regular 24 hour oral morphine dose, as required. Assess 30 - 60 minutes after a breakthrough dose and if pain persists then give a second breakthrough dose.
• If switching opioids see either flowchart (link below) or more detailed information, including opioid choice is available at www.palliativecareguidelines.scot.nhs.uk.

• Flowchart Opioid Conversion Chart.

Renal Impairment

Morphine and oxycodone must be used with caution in patients with eGFR <60ml/minute/1.73m². See www.palliativecareguidelines.scot.nhs.uk, pain section then select 'Choosing and Changing Opioids' for further information. Contact local Palliative Care team for advice on alternative opioids. With NSAIDs, avoid if possible in renal impairment. For further cautions / contraindications with NSAIDs see Prescribing Notes for Acute Pain for detail.

Breakthrough pain (as required PRN)

• For same opioid and route: divide 24 hour opioid dose by 1/6 to 1/10. Prescribe hourly on kardex and state in additional instructions/comments box “maximum of 6 doses in 24 hours. If 3 or more doses required within a 4 hour period with little or no benefit seek urgent advice/review".
• For guidance on conversion to or from fentanyl patch see www.palliativecareguidelines.scot.nhs.uk.
• Consider increasing the breakthrough opioid dose as the background opioid dose increases.

Opioid toxicity (seek advice)

Signs include:

• Increased drowsiness / sedation
• Vivid dreams / hallucinations / delirium
• Muscle twitching / myoclonus / jerking
• Abnormal skin sensitivity to touch

Treat by reducing opioid dose by 1/3, ensure patient is well hydrated, review and re-titrate the analgesia. Consider adjuvant therapies and/or alternative opioids. For naloxone dosing guidance in other circumstances, see Reversal of Opioid-induced Respiratory Depression. If patient is in renal or hepatic impairment seek dosing advice from your clinical pharmacist or senior member of medical staff or local palliative care team.

Adjuvants (in persistent pain and palliative care)

NSAIDs

Consider NSAIDs for bone pain, liver pain, soft tissue infiltration or inflammatory conditions. If topical NSAID is required then consider ibuprofen 5% gel applied up to 3 times daily. For systemic NSAID options, see Prescribing Notes for Acute Pain.

Note: diclofenac may be used subcutaneously in palliative care patients. Please contact Palliative Care team for advice on dosing and administration.

Other adjuvant therapies

• For neuropathic pain signs and symptoms include burning, shooting, stabbing, throbbing, electric shocks / spasms, numbness, pain not relieved by rest. Consider low dose anticonvulsants and/or tricyclic antidepressants, e.g.:
  • Gabapentin oral: 
    • In elderly / frail patients - initial starting dose is 100mg, can be increased by 100mg daily (as tolerated) to a maximum of 300mg three times a day.
    • In fitter patients - titrate dose from 300mg as per BNF, up to a maximum of 600mg three times a day.

    Specialists may recommend higher doses of gabapentin. Reduce dose in patients with renal impairment and seek specialist advice. For further information refer to neuropathic pain section at www.palliativecareguidelines.scot.nhs.uk

  • Amitriptyline oral: initial dose 10mg at night. Can be slowly titrated in 10mg increments every 5 - 7 days, maximum 100mg/daily.
  Note: Neuropathic pain may not fully respond to opioids.
• Dexamethasone - Consider for intracranial, nerve or liver pain, but dose varies:
  • Intracranial pressure - dexamethasone oral 8 to 16mg each morning (doses above 8mg given in divided doses before 4pm)
  • Nerve pain - dexamethasone oral 4 to 8mg each morning
  • Liver pain - dexamethasone oral 4mg to 8mg each morning 

For further information refer to dexamethasone medicine information sheet at www.palliativecareguidelines.scot.nhs.uk. Consider gastroprotection and monitor blood glucose.

For all adjuvants reduce to the lowest effective dose.

Special circumstances

Swallowing difficulties:

If patients struggle to swallow analgesics in tablet form, consider switching to liquid preparations or parenteral alternatives. Seek advice from a pharmacist. Do not crush tablets before discussing with a pharmacist.

If patients are advised to take "nil by mouth", consider switching to parenteral alternatives. Note that IV paracetamol can only be given on a named patient basis by consultant request when oral or rectal administration is not possible.

PEG tubes:

Consider switching to liquid preparations or parenteral alternatives. Seek advice from a pharmacist. Some medications should not be given via PEG tubes even if crushed or in liquid form.

Guideline reviewed: September 2023

Page last updated: December 2023