Overview of opioid use in palliative care

Palliative Care Australia (PCA), 2019

Opioids are the cornerstone of management for a variety of symptoms in palliative care, particularly pain and breathlessness. When prescribing an opioid for patients with palliative care needs, consider:

• factors influencing opioid choice
• that older, frail or cachectic patients are more susceptible to the effects of opioids and generally need a lower initial dose
• organ dysfunction—all opioids are metabolised by the liver and may need dosage adjustment in liver impairment (see Considerations with opioid use in liver impairment); some opioids may be preferred to others in kidney impairment
• how response will be assessed (eg whether opioid therapy is meeting the patient’s goals of care)
• how adverse effects will be prevented and managed
• the risk of misuse, abuse and diversion—see Opioid misuse, abuse and diversion in the Pain and Analgesia guidelines for general information, including resources available for checking before prescribing (eg real-time prescription monitoring services)
• how the opioid will be safely stored, transported and disposed of, particularly in patients with children in their care
• addressing patient, family and carer concerns about opioid use.

Although opioids play an essential part in minimising unnecessary pain and suffering in patients with palliative care needs, the risk of harm associated with long-term opioid use must be minimised. Monitor patients taking an opioid—assess for appropriateness of opioid use and dose, harms associated with opioid use, and whether the patient’s goals of care are being met.

For patients who have been taking opioids long term, an interruption in therapy may cause a withdrawal syndrome. This is a particular concern when moving patients between care settings (eg from home to hospital, between hospitals, discharge from hospital), when doses may be missed—for advice, see Medication management when moving between care settings. If the patient’s usual opioid is not available in a timely manner, conversion to an alternative, dose-equivalent option may be needed—see Overview of switching opioids in palliative care. Specialist input may be required.

For opioid use in children with palliative care needs, seek specialist advice.