Pain management

Question 1

What is malignant pain?

Answer 1

Tissue damage caused by malignant tumours. tumour in the tissue/organ. can be constant or ‘breakthrough pain’

nociceptive pain: tissue/organ distortion or injury (somatic = bone, muslce) (visceral = gut, bladder)

neuropathic pain: damage to the nerve fibres

Question 2

define constant pain

Answer 2

constant pain-
tumour causing pressure (distention / stretch)
not affected by position or activity. more likely in confined space (skull, pelvis)
constant and unchanged

Question 3

what is breakthrough pain

Answer 3

rare flare-up, rapid onset, moderate=severe intensity, short duration,

Question 4

define neuropathic pain

Answer 4

damage to nerve fibres, peripheral and central nervous system changes

burn, stabbing, hyperaesthesia
unpredictable
less responsive to opioid analgesics

Question 5

opiate dose equivalent chart

on st Lukes website) (Ratios

Answer 5

codeine is x10 weaker than morphine (60mg codeine= 6mg morphine)

25mcg of fentanyl = 90mg oral morphine

fentanyl is the least constipating (morphine and codeine are very constipating- prescribe laxative and senna)

Question 6

what is the ratio for breakthrough doses?

Answer 6

a total daily dose of background dose (240)

divide by 6= 40mg

40mg is the breakthrough dose of oramorph

Question 7

what is the oral oxycodone and oral morphine ratio?

Answer 7

twice as potent as oral morphine

20mg of morphine
/2
10mg oxycodone

Question 8

what is the oral morphine to subcutaneous diamorphine ratio?

Answer 8

switch from oral to subcut if unable to swallow, nausea and vomiting, dysphagia, last days of care, coma

ratio divide by 3 subcut diamorphine

subcut morphine divide by 2

Question 9

neuropathic pain tx

Answer 9

corticosteroids
morphine
gabapentin (anticonvulsant)
tapentadol

Question 10

renal impairment- opiate toxicity

Answer 10

morphine is metabolised to M6G and relies on the kidneys to excrete so if renal impairment, cannot clear their morphine= side effects

drowsy, confused
pinpoint pupils (muscle contraction)
myoclonic jerks

Question 11

renal impairment- opiate toxicity

Answer 11

morphine is metabolised to M6G and relies on the kidneys to excrete so if renal impairment, cannot clear their morphine= side effects

drowsy, confused
pinpoint pupils (muscle of the iris contraction)
myoclonic jerks

naloxone to reverse opiates

Question 12

WHO pain ladder

Answer 12

non-opioid +/- adjuvant

opioid for mild-moderate pain + non-opioid + adjuvant

opioid for moderate to severe + nonopioid + adjuvant

Question 13

MOA opioids

Answer 13

agonist for specific receptor sites at nerve cell synapse

Mu, kappa, delate receptors

Question 14

weak opioids

Answer 14

oral codeine
transdermal buprenorphien (weekly patches)
oral tramadol

Question 15

strong opioids

Answer 15

use is dictated by the therapeutic need, not by prognosis

morphine, diamorphine, alfenanil (injectable), fentanyl, oycodone, tapentadol, methadone

Question 16

prescribing oral morphine (oramorph)

Answer 16

immediate release
oramorph liquid 4 hrly, PRN
sevredol tablets

slow release
zoramorph- release over 12hrs
MST tablet bd
MXL capsules bd

Question 17

oxycodone

Answer 17

strong opioid used 2nd-3rd line

Question 18

fentanyl

Answer 18

pure mu-opioid
highly lipid-soluble
poor oral absorption
useful in renal failure

transdermal fentanyl skin patch

transmucal? formulations for breakthrough pain
effector (buccal)

Question 19

alfentanil

Answer 19

10 times as potent as SC diamorphine

Question 20

common opioid side effects

Answer 20

nausea

constipation

Question 21

adjuvant analgesics

Answer 21

1. corticosteroids
   dexamethasone (in palliative)

nerve compression 4-8mg dex

2. amitryptiline TCA 10-50mg nocte (night)
3. gabapentin 300mg. nerve caclium channel blocker
4. pregabalin 25-300mg bd

Question 22

other adjuvant analgesics

Answer 22

laxatives
antispasmodics (hyoscine bultyblromide- buscopan)
antibiotics (ulcerated and infected tumours)

Question 23

Interventional techniques

Answer 23

epidural analgesia

intrathecal spinal analgesia

local nerve infiltration

sympathetic plexus blockade

Question 24

just in case medication

anticipatory medicine

Answer 24

given by injection / syringe pump and to be kept at home in case you need them. try usual oral meds first.

• pain relief
• sickness / nausea
• breathlessness / secretions
• anxiety / restlessness
• diamorphine for severe pain
• cyclizine for sickness
• midazolam for relaxing muscle
• hyoscine or glycopyronium to dry up secretions from the mouth/chest
• haloperidol for anxiety
• water to dissolve other meds

Question 25

JIC on St Lukes South West Devon Formulary

Answer 25

2 x ampoules of morphine sulfate 10mg/1ml for pain or breathlessness at a dose of 2.5 to 5mg when required s/c*
2 x ampoules of levomepromazine 25mg/mL for nausea and vomiting
3 x ampoules midazolam 10mg/2mL for restlessness, anxiety, agitation and breathlessness
2 x ampoules of haloperidol 5mg/mL for nausea, hallucinations and agitation
3 x ampoules of hyoscine hydrobromide 400 microgram/ml or hyoscine butylbromide 20mg/mL or glycopyrronium 200 micrograms/mL for respiratory tract secretions

Question 26

amboss pain

Answer 26

Administration of slow-release opioids according to a fixed time schedule and use of PRN medication (fast-acting opioids

, injections)
Opioid dosage should be increased in terminally ill patients to provide sufficient pain relief.
For details, see pain management.
Nociceptive pain

Neuropathic pain
See also pain concepts in palliative care.

Question 27

amboss GI symptoms

Answer 27

Nausea and vomiting: metoclopramide , haloperidol, levomepromazine , dimenhydrinate
Loss of appetite: dexamethasone or prednisolone
Thirst: oral care
Constipation

: lactulose, macrogol, sodium picosulfate, paraffin
Diarrhea

Addressing the possible cause (paradoxical diarrhea

or administration of laxatives should be excluded)
Fluid and electrolyte replacement from an early stage on

Question 28

amboss pulmonary symptoms

Answer 28

Dyspnea: fast-acting morphine (e.g., morphine drops); breathing and relaxation techniques
Cough: Treatment depends the type of cough (productive/non-productive) and either involves administration of protussives or antitussives. In refractory disease, hydrocodone may be an option. Corticosteroids may be an alternative.

Question 29

amboss psychological symptoms

Answer 29

Anxiety and depression: benzodiazepines, antidepressants, antipsychotics, and psychotherapy
Delirium: antipsychotics, benzodiazepines

Fatigue
Regular exercise, physical therapy, and psychotherapy have been shown to have positive effects.
Corticosteroids (e.g., dexamethasone, methylprednisolone) may be used to improve short-term stamina.

Question 30

amboss final phase meedicines

Answer 30

Restlessness/agitation: midazolam, lorazepam
Delirium: haloperidol

, metoclopramide
Death rattle: butylscopolamine, if necessary [2]

Question 31

death rattle

Answer 31

due to excessive respiratory secretions
reassure relatives
treat prophylactically:

non sedative- glocopyrronium 200ug sc sta review after 1 hr, 4 hr

sedative-
hyoscine 400ug / 4-8hr SC or via transdermal patch