Pain

Question 1

History of pain

Answer 1

SQITARS
Associated symptoms - breathlessness, bowels
Treatments already tried - frequency and dose
ICE

Question 2

Features of pain in advanced disease

Answer 2

Persistent
Multiple aetiologies
Impairs function
Fear of cancer worsening

Question 3

Causes of chest pain in cancer pateints

Answer 3

Cancer related - bone mets, invasion, malignant spinal cord compression

Treatment related - reaction to radiotherapy, oesophagitis, pneumonitis

Other medical conditions - Pneumonia, pneumothorax (biopsy), PE, MI, anxiety, MSK

Question 4

Pathophysiology nociceptive pain

Answer 4

Caused by an identifiable lesion causing tissue damage which stimulates pain receptors in the normal nervous system

Question 5

Features of somatic nociceptive pain

Answer 5

Sharp
Throbbing
Well localised

Question 6

Pathophysiology of neuropathic pain

Answer 6

Caused by damage to the nervous system e.g. spinal cord compression

Question 7

Pathophysiology of neuropathic pain

Answer 7

Caused by damage to the nervous system e.g. spinal cord compression

Question 8

Features of visceral nociceptive pain

Answer 8

Diffuse ache

Difficult to localise

Question 9

Features of neuropathic pain

Answer 9

Stabbing or shooting 
Burning 
Numbness or pins and needles 
Electric shock 
Hypersensitivity

Question 10

Types of analgesics

Answer 10

Non- opiods
Adjuvants
Opiods

Question 11

Examples of non-opiods

Answer 11

Paracetamol

Ibuprofen and other NSAIDs - diclofenac, naproxen

Question 12

Examples of adjuvants

Answer 12

Anti - convulsant - Gabapentin, pregabalin
Antidepressants - Amitriptyline (TCA), duloxetine (SNRI)
Benzodiazepines - Diazepam, clonazepam
Bisphosphonates - for bone pain

Question 13

Examples of opioids

Answer 13

Morphine 
Fentanyl 
Tramadol 
Oxycodone 
Dihydrocodeine

Question 14

WHO analgesic ladder

Answer 14

1. Non-opioid
   +/- adjuvant
2. Opioid for mild/moderate pain
   +/- non-opioid
   +/- adjuvant
3. Opioid for moderate/ severe pain
   +/- non-opioid
   +/- adjuvant

Question 15

COX2 NSAIDs and interactions

Answer 15

If there is no CV or GI risk - ibuprofen, diclofenac, naproxen

If there is a GI risk - COX 2 - celecoxib

If there is a CV risk - naproxen, ibuprofen

Question 16

What is also prescribed with NSAIDs

Answer 16

PPI

Question 17

When to give analgesics

Answer 17

Consider with pain that is only partially responsive to opioid analgesia

Opioid sparing effect

Question 18

Drugs for neuropathic pain

Answer 18

Amitriptyline - prescribe at night
Gabapentin
Pregabalin

Question 19

Advice for neuropathic pain medication

Answer 19

Takes at least 5 days for full benefit

May need further titration

Question 20

Side effects of amitriptyline

Answer 20

Confusion
Sedation
Hypotension
Care with CVS disease

Question 21

Side effects of pregabalin and gabapentin

Answer 21

Confusion 
Sedation 
Tremor 
Dizziness 
Care with renal impairment

Question 22

WHO principles for analgesics

Answer 22

By mouth where possible 
By the clock rather than by pain 
By the ladder 
If adjusting SR, adjust PRN 
Use adjuvants at any step

Question 23

Examples of 1st, 2nd and 3rd line analgesics

Answer 23

Step 1: Paracetamol and NSAIDs

Step 2: Dihydrocodeine, codeine phosphate, tramadol, co-codamol

Step 3: Oxycodone, morphine, fentanyl, diamorphine

Question 24

Liver pain

Answer 24

Give dexamethasone to decrease inflammation

NSAIDs

Question 25

Converting between codeine and morphine

Answer 25

10: 1 codeine: morphine | e. g. 240mg codeine = TDD 24mg morphine

Question 26

Slow-release and PRN immediate-release morphine calculation

Answer 26

Slow release = TDD/ 2 | PRN = TDD/ 6

Question 27

Max number of PRN morphine doses in 24hrs

Answer 27

6

Question 28

Immediate-release morphine

Answer 28

Oramorph liquid - 10mg/5ml

Question 29

Slow-release morphine

Answer 29

Zomorph capsules BD MST tablets BD - used for small doses Take 12 hourly

Question 30

Common side effects for opioids

Answer 30

Constipation - give laxative Dry mouth Nausea and vomiting - give anti-emetic Drowsiness/ sedation - normally gets better and can drive if they feel fine

Question 31

Opioids and respiratory distress

Answer 31

Check renal function as occurs with renal failure

Question 32

Opioids and addiction

Answer 32

If used appropriately and at the right dose, it shouldn't be a problem

Question 33

Opioids and approaching the end of life

Answer 33

Often this slows the progression of deconditioning so there is a better quality of life

Question 34

Fentanyl features

Answer 34

Transdermal patch Non renally excreted Takes 12 - 24 hrs to reach steady state

Question 35

Fentanyl and morphine

Answer 35

12mcg/hour patch = 45mg TDD morphine 45/6 = 7.5mg - prescribe 8mg oramorph PRN

Question 36

Syringe driver morphine

Answer 36

Delivered subcut - 1/2 24 hour oral dose e.g. if 50mg zomorph BD = morphine 50mg/24hr via SCSD

Question 37

Opioid toxicity presentation

Answer 37

``` Pinpoint pupils Hallucinations Drowsiness Vomiting Confusion Myoclonic jerks Respiratory depression ```

Question 38

When does opioid toxicity present

Answer 38

If dose is escalated too quickly Renal impairment - withhold zomorph and check renal function Poor opioid responsive pain but escalated Intervention to reduce pain such as nerve block and given opioid

Question 39

Controlled drug prescription

Answer 39

- Name and ID of the patient - Write prescription as normal - Write supply and give pharmacist exact instructions - Drug name and the formulation and strength - Total no. of tablets in words and figures