Managing common side effects of opioids for

pain relief in palliativ

palliativee care

NICE Pathways bring together all NICE guidance, quality standards and other NICE
information on a specific topic.

NICE Pathways are interactive and designed to be used online. They are updated
regularly as new NICE guidance is published. To view the latest version of this pathway
see:

http://pathways.nice.org.uk/pathways/opioids-for-pain-relief-in-palliative-care
Pathway last updated: 08 August 2016

This document contains a single pathway diagram and uses numbering to link the
boxes to the associated recommendations.

Copyright NICE 2016. All rights reserved

 Managing common side effects of opioids for pain relief in palliativ
palliativee care NICE Pathways

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1 Person receiving treatment with strong opioids

No additional information

2 Managing constipation

Inform patients that constipation affects nearly all patients receiving strong opioid treatment.

Prescribe laxative treatment (to be taken regularly at an effective dose) for all patients initiating
strong opioids.

Inform patients that treatment for constipation takes time to work and adherence is important.

Optimise laxative treatment for managing constipation before considering switching strong
opioids.

See the NICE pathway on constipation.

Naloxegol

The following recommendation is from NICE technology appraisal guidance on naloxegol for
treating opioid-induced constipation.

Naloxegol is recommended, within its marketing authorisation, as an option for treating opioid-
induced constipation in adults whose constipation has not adequately responded to laxatives.

An inadequate response is defined as opioid-induced constipation symptoms of at least

moderate severity in at least 1 of the 4 stool symptom domains (that is, incomplete bowel
movement, hard stools, straining or false alarms) while taking at least 1 laxative class for at
least 4 days during the prior 2 weeks.

NICE has written information for the public explaining its guidance on naloxegol.

Methylnaltrexone

The appraisal of methylnaltrexone for treating opioid-induced bowel dysfunction in people with
advanced illness receiving palliative care was terminated because evidence submission was
received from the manufacturer of the technology. Therefore NICE is unable to make a
recommendation about the use in the NHS of methylnaltrexone for treating opioid-induced
bowel dysfunction in people with advanced illness receiving palliative care.

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3 Managing nausea

Advise patients that nausea may occur when starting strong opioid treatment or at dose
increase, but that it is likely to be transient.

If nausea persists, prescribe and optimise anti-emetic treatment before considering switching
strong opioids.

4 Managing drowsiness

Advise patients that mild drowsiness or impaired concentration may occur when starting strong
opioid treatment or at dose increase, but that it is often transient. Warn patients that impaired
concentration may affect their ability to drive1 and undertake other manual tasks.

In patients with either persistent or moderate-to-severe central nervous system side effects:

consider dose reduction if pain is controlled or

consider switching opioids if pain is not controlled.

If side effects remain uncontrolled despite optimising treatment, consider seeking specialist
advice.

1
For more information see the DVLA website

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Background and breakthrough pain

Background pain is chronic, persistent pain. Breakthrough pain is a transient increase in pain
intensity over background pain, typically of rapid onset and intensity, and generally self-limiting
with an average duration of 30 minutes.

Immediate-release

A dosage form that is intended to release all the active ingredient on administration with no
enhanced, delayed or extended release effect.

Rescue doses

A rescue dose is the dose of analgesic needed for the relief of breakthrough pain.

Strong opioids

Morphine-like drugs (such as diamorphine, fentanyl, oxycodone, buprenorphine). Codeine and

dihydrocodeine are weak opioids.

Subcutaneous opioids

A subcutaneous injection of opioids is given in the fatty layer of tissue just under the skin.

Sustained-release

A dosage form that is designed to release a drug at a predetermined rate by maintaining a

constant drug level for a specific period of time with minimal side effects.

Transdermal patches

Medicated adhesive patches that are placed on the skin to deliver a specific dose of medication
through the skin into the bloodstream.

Sources

Palliative care for adults: strong opioids for pain relief (2012 updated 2016) NICE guideline
CG140

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Naloxegol for treating opioid-induced constipation (2015) NICE technology appraisal guidance
TA345

Methylnaltrexone for treating opioid-induced bowel dysfunction in people with advanced illness
receiving palliative care (terminated appraisal) (2013) NICE technology appraisal TA277

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright

Copyright National Institute for Health and Care Excellence 2016. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.

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