Skip to 0 minutes and 9 secondsPatients, if they do get a side effect that you could have anticipated, and maybe that side effect has been caused by whether too fast a titration or maybe a wrong opiate for that patient, then they can suffer a side effect. And then unfortunately, the side effect can put patients off and they're actually then afraid to retry the opiate. If that actually happens, then your options become limited. And the concern would be substandard analgesic really. So I also see a lot of issues for it with breakthrough cancer pain about interval prescribing. So we can understand why we have to have intervals for such strong opiates.

Skip to 0 minutes and 49 secondsHowever, sometimes again, you've heard of the patient clock watching and wondering when their next dose is due, and again, can end up in substandard care. And substandard pain relief. Some other issues I do find on the flip side, is actually, some doctors are worried about prescribing opiates at all. You do sometimes still hear about worrying about respiratory depression, for example, which of course, is a risk of strong opiates. But again, if one doesn't make the initial assessment and it is actually safe to prescribe, but they're afraid to, which again, ends up in substandard pain relief really. Yeah. I would certainly agree with the point that you've made there about the breakthrough pain.

Skip to 1 minute and 36 secondsI think that is probably the most common issue that I see in my practice, is that a patient is prescribed immediate release opioid for breakthrough pain, but the frequency or the dose isn't correct. Review is so vitally important. Ideally, it should be done by the person who's initiated the opiate. Because it's well known that continuity of care patients do better. I do appreciate in today's NHS, it can be difficult to do that. So what you can then do, is just make sure that somebody who is trained and is skilled to work out if the opiate's agreeing with your patient or not. And I think it's really important. Because again, you don't want to lose the trust in the patient.

Skip to 2 minutes and 21 secondsThe aim here at the centre of all this, is obviously the patient, and why you're actually commenced the opiate. So I suppose you're reviewing for in particular, side effects, and management of side effects. And making sure that actually why you've started it, it's actually having its purpose and it's working. Because if something's not working, then you need to go back to the basics. And review again. And review again.

Common mistakes

As we are beginning to appreciate, prescribing opioids is inherently complex and therefore prone to error.

In this video Dr Hewitt and Dr Coulter discuss some of the mistakes which commonly happen when prescribing opioids.

These drugs have many side effects to be aware of, each requiring a specific management strategy. Cancer pain is often unstable due to disease progression and the effect of oncology treatments or surgery. Add in the fact that healthcare resources are often in high demand and the potential for mistakes to occur increases considerably.

Common issues that affect pain control with opioids include:

  • incorrect dose of immediate release (IR) opioid for breakthrough pain
  • failure to increase/ decrease the breakthrough dose of IR opioid at the same time as increasing/ decreasing the background MR dose.
  • breakthrough analgesia intervals set too wide, leaving the patient in pain and “clock-watching” for the next dose
  • inadequate review: problems are not identified and managed in a timely manner
  • failure to anticipate and proactively manage side effects
  • using more than one different type of opioid at the same time
  • prescribing fentanyl or buprenorphine patches for unstable pain

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This video is from the free online course:

Opioid analgesics: Treating Pain in People with Cancer

Newcastle University

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