New pain control guidelines which cover palliative care have been published by the Royal College of Physicians. They say that despite doctors' concerns, morphine can be used safely to relieve pain without shortening life.
Two-thirds of terminally ill patients experience pain, whatever the underlying diagnosis, the guidelines say. The aims of management in palliative care are to control the patient's symptoms, make quality of life as good as possible and enable the patient to do what he or she wants. In terminally ill patients, the mainstay of treatment is opioids, particularly morphine. Morphine is not addictive, is safe when titrated against the patient's pain and does not seem to shorten life, according to the guidelines. Doses of morphine can be increased, if needed, provided that they "produce better pain relief and not intolerable side effects".
The guidelines also cover situations where morphine appears to be ineffective. They say that a lack of improvement following a dose increase, accompanied by worse side effects, could have of a number of underlying causes, including hypercalcaemia of malignancy, bone/joint pain and skin pain. The suggested solution is to add another drug, such as a non-steroidal anti-inflammatory for bone pain or an anti-depressant for neuropathic pain. In cases where the side effects of morphine become intolerable, an alternative opioid could be tried, the guidelines say. Other problems, such as additional physical symptoms, depression or spiritual anxieties could make the patient unable to deal with pain.
Delivery of morphine is also discussed. Many patients are no longer able to swallow medication near the end of life, so transdermal patches, rectal preparations and continuous subcutaneous infusions could be used instead. The intravenous route is not a first choice alternative, the guidelines say. Continuous subcutaneous infusion using syringe drivers can deliver a range of drugs, most commonly diamorphine, anti-emetics and sedatives. Ideally, no more than two drugs should be mixed in the same syringe, although occasionally three are used, the guidelines say.
They add that, in terms of normal medication, only drugs which control or prevent distressing symptoms should be given. Drugs for long-term conditions, for example, antihypertensives, can be discontinued.
"Principals of pain control in palliative care for adults" are on the College's website (http:// www.rcplondon.ac.uk/pubs/wp_pc_home.htm).