Home' Australian Pharmacist : Australian Pharmacist May 2013 Contents 70 Australian Pharmacist May 2013 I ©Pharmaceutical Society of Australia Ltd.
Continuing Professional Development
such as faecal impaction. Clinical trials
have shown that transdermal fentanyl has
been preferred by cancer patients over
slow release oral morphine and may cause
less constipation.21 As pain is a potent
respiratory stimulant, respiration depression
is rare, especially if doses are increased
slowly with accompanying sedation.
Changing between opioids and routes of
administration may minimise and alter the
adverse effect experience.
Breakthrough doses are calculated as
one-twelfth to one-sixth of the total daily
dose and can be given prior to an event
or activity likely to result in incident pain.10
Whilst high level evidence is lacking, there is
an emerging practice of individual titration
rather than a fixed ratio of the breakthrough
dose to the background opioid. A 'pain pen'
is in development, which may potentially
make subcutaneous administration of
breakthrough pain analgesia convenient for
Non-pharmacological strategies for
managing pain in palliative care can have
significant clinical benefits despite limited
studies in this area. They include patient
and carer education on self-management
strategies, transcutaneous electrical nerve
stimulation (TENS), hot/cold packs, music
therapy, acupuncture, hypnosis, massage
reflexology, mind-body therapies, art
therapy and biofield therapy. They provide
patients with options other than analgesics
alone and empower patients to remain
proactive in the planning of their
The role of pharmacists
Community and consultant pharmacists
have an important role to play in the relief
of pain in palliative care particularly as,
on average, terminally-ill patients will
spend 90% of their final year at home.2
In hospitals, palliative care pharmacists
are a recognised specialty and part of the
interdisciplinary palliative care team.
The expansion in role and inclusion
of pharmacists in the interdisciplinary
framework of palliative care initiatives was
represented by the Pharmacy Guild in
the March 2012 Submission to the Senate
Inquiry on Palliative Care in Australia. The
submission advocates for the delivery of
enhanced palliative care services where
community pharmacists are involved
and the inclusion of specifically trained
pharmacists as part of a multidisciplinary
team through a Palliative Care Medication
Management Review service. For
pharmacists to expand and be significantly
involved in this area of practice, proactive
learning to develop base knowledge and
skills is essential.
In the case of Amy's deteriorating
end-stage renal failure her pharmacist can
help her with:1,23,24
• Assessing the appropriateness of all
her prescribed medicines (including
palliative care medicines) and
• Educating Amy on the effectiveness of
her prescribed analgesics and non-drug
strategies for symptom control.
• Providing Amy with resources such as
palliative care or pain support groups
that will give her and her family the
emotional support she may need.
• Discussing Amy's financial status
and cost effective use of the PBS, in
particular the palliative care items listed
on the PBS; where necessary, discussing
these options with her doctor.
• Individualising Amy's analgesics and
other prescribed medicines so that
if extemporaneous compounding of
non-standard dosage forms is required,
these options are offered.
• Assessing and enhancing medication
compliance and ensuring that
directions provided with medicines are
understood and being followed.
• Discussing the benefits of dose
administration aids in terms of
promoting patient independence
and safety, particularly if she is on
increasing prescribed medicines.
• If Amy plans to travel around Australia,
arrange sufficient medication or advise
and clarify regulatory discrepancies
between jurisdictions in the prescription
of controlled drugs often used in
• Observe Amy for distress such as
depression, anxiety and crises, which
may be secondary to the end-stage
renal failure. Early identification will limit
the number of frequent acute care visits.
• Educate Amy on the safe storage and
disposal of all medicines so that the
integrity of medicines is preserved, as well
as minimising risk to the general public.
• Palliative Care Australia. Standards for
Providing Quality Palliative Care for all
• Therapeutic Guidelines. Palliative Care,
Version 3. 2010.
• The Society of Hospital Pharmacists of
Australia. Standards of Practice for the
Provision of Palliative Care Pharmacy
Professional development and
• Care Search -- Palliative Care Knowledge
• National Institute for Health and
Clinical Excellence: www.nice.org.uk
• The WA Cancer & Palliative Care
Network brochure: Essential palliative
care medications list for community
pharmacists and general practitioners:
• Australian Pain Management Association:
• Pain Australia: www.painaustralia.org.au
1. Jiwa M, O'Connor M, Hughes J, Fisher C, Mullan J et al. The
role of the Pharmacist in the Provision of Palliative Care Final
Report. Curtin University of Technology for The Pharmacy Guild
of Australia Fourth Community Pharmacy Agreement Research
& Development Program; 2007.
2. Hussainy SY, Box M, Scholes S. Piloting the role of a pharmacist
in a community palliative care multidisciplinary team: an
Australian experience. BMC Palliative Care. 2011; 10:16
3. WHO Definition of Palliative Care. World Health Organization.
Retrieved 23rd February 2013
4. Haines, IE. Managing patients with advanced cancer: the
benefits of early referral for palliative care. Med J Aust 2011; 194
5. An Ethical Framework for Integrating palliative care principles
into the management of advanced chronic or terminal
conditions. September 2011. NHMRC
6. Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop
R, Lipsitz L, Steel K and Mor V, for the SAGE Study Group.
Management of pain in elderly patients with cancer. JAMA.
EVIDENCE IN PATIENT CARE
strategies for managing
pain in palliative care
can have significant
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