Pain

Question 1

What are some cancer related issues that can cause pain?

Answer 1

Bone invasion
Nerve compression
soft tissue infiltration
visceral stretch/infiltration
muscle spasm
raised intracranial pressure

Question 2

What are some Treatment related issues that can cause pain?

Answer 2

surgeyr side effects
chemotherapy side effects
radiotherapy side effects
phantom limb pain

Question 3

What is the starting dose of morphine for an opioid naive patient?

Answer 3

5-10mg, immediate release every 4-6 hours with PRN doses

Question 4

What is the conversion factor from codeine to morphine?

Answer 4

Divide the 24 hr codeine dose by 10 to give 24hr morphine dose

Question 5

How is a PRN dose calculated?

Answer 5

Is 1/6 of the 24 hr total dose.

Question 6

Define Nociceptive pain

Answer 6

Pain which results due to stimulation of intact nerves.

Question 7

What is somatic pain?

Answer 7

Pain due to damage to tissue

Question 8

What is visceral pain?

Answer 8

Pain due to a lesion in or a lesion causing compression to a hollow viscous/solid organ

Question 9

What are the types of neuropathic pain?

Answer 9

Peripheral - damage to peripheral nervous system.
Central - caused by damage to brain/spinal cord

Question 10

Define Background pain

Answer 10

Persistent long term pain managed by regular analgesia

Question 11

Define Breakthrough pain

Answer 11

Transient exacerbations of pain, above the regular background pain not controlled by regular analgesia. Often short lived and moderate/severe in intensity

Question 12

Define allodynia

Answer 12

Pain caused by a stimulus that does not normally cause pain

Question 13

Define hyperalgesia

Answer 13

Increase response to a normally painful stimulus

Question 14

Behaviours which could indicate someone is in pain

Answer 14

Vocalisations
Facial expressions
Change in body language
Physical changes
Physiological change

Question 15

What are some Behavioural assessment tools that can be used in people with advance dementia?

Answer 15

DS-DAT - Discomfort scale for dementia of alzheimers type
DisDAT - Disability distress assessment scale
Abbey Pain scale - commonly used in care homes

Question 16

What is step 1 of opioid ladder?

Answer 16

non-opioid +/- adjuvant

Question 17

What pain level dose step 1 roughly equate to?

Answer 17

mild to moderate pain

Question 18

What is step 2 of opioid ladder?

Answer 18

Weak opioid + non-opioid +/- adjuvant

Question 19

What pain level does step 2 roughly equate to?

Answer 19

Moderate pain - pain persisting/increasing

Question 20

What is step 3 of opioid ladder?

Answer 20

Strong opioid + non-opioid +/- adjuvant

Question 21

What pain level does step 3 roughly equste to?

Answer 21

moderate to severe pain

Question 22

How do opioids work?

Answer 22

Block pain receptors (mainly found in dorsal horn of spinal cord, brain stem and peripheral nerves)

Question 23

What would a starting dose of morphine be?

Answer 23

5-10mg immediate release morphine, every 4-6 hours, plus PRN doses

Question 24

By what increment would an analgesic be increased when uptitrating the dose?

Answer 24

Calculate PRN doses plus regular doses.
can make these then new BD doses
increase in 30% increments

Question 25

How would you calculate a dose change when switching opioids?

Answer 25

Calculate 24 hr dose, then reduce this by 1/3rd then can titrate accordingly.

Question 26

Dose conversion from PO to SC morphine/oxycodone

Answer 26

divide by 2

Question 27

Dose conversion for PO morphine to alfentanil in CSCI

Answer 27

divide 24 hr dose by 30

Question 28

Dose conversion for PO morphine to Diamorphine in CSCI

Answer 28

divide 24 hr dose by 3

Question 29

When would you consider switching morphine to fentanil?

Answer 29

Need to be on at least 60mg PO morphine/equivalent

Question 30

Dose conversion for PO/rectal route

Answer 30

Should be equivalent

Question 31

When would you consider switching morphine to diamorphine?

Answer 31

Convenient for syringe driver use when high doses of opioids are needed as it comes in powder form and is highly soluble in water.

Question 32

When would you use Alfentanil?

Answer 32

Renal failure, needing opioid via CSCI

Question 33

What is some "sensible driving advice" that can be given when starting opioids?

Answer 33

- Avoid driving for 5 days after changing dose - Avoid driving within 4 hrs of extra breakthrough dose - Avoid driving until you feel 100% safe to do so - When restarting, aim for short trips on familiar roads in daylight with a companion if possible There is no legal requirement to inform DVLA, but insurance companies often suggest to.

Question 34

What should also be co-prescribed with a new opioid?

Answer 34

Laxatives (stimulant nad softener) Anti-emetics (metoclopramide 10mg TDS for 5 days, then PRN)

Question 35

When is opioid toxicity more likely to occur?

Answer 35

Rapid upward titration Renal failure - accumulation of active metabolites. Conversion from other opioids Change in preparation e.g. PO to SC Development of acute infection Starting adjuvant medicaitons

Question 36

When can topical opioid absorption be increased?

Answer 36

During pyrexia

Question 37

What are some symptoms and signs of opioid toxicity?

Answer 37

Drowsiness Myoclonic jerks Pinpoint pupils (poor discriminating sign) Confusion/agitation Hallucinations Vivid dreams Cognitive impairment Respiratory depression

Question 38

How to manage mild opioid toxicity?

Answer 38

Reduce dose of opioid Consider rehydration Treat any underlying cause e/g infection, high calcium

Question 39

What can be used if agitation/confusion is causing issues with opioid toxicity?

Answer 39

Haloperidol 0.5mg-3mg PO/SC

Question 40

How to manage moderate opioid toxicity?

Answer 40

If RR more than 8, SpO2 norma and no cyanosis - Omit next dose - "wait and see" When more stable, restart at lower dose

Question 41

How to distinguish moderate vs severe opioid toxicity?

Answer 41

RR <8 Reduced SpO2 Cyanosis is present

Question 42

What is used to treat severe opioid toxicity?

Answer 42

Naloxone (100-200 microgram, ever 2-3 mins until RR is satisfactory)

Question 43

How can malignant bone pain be treated?

Answer 43

Bisphosphonates NSAIDs Palliative Radiotherapy