pain + palliative care Flashcards
(23 cards)
WHO pain ladder
- non-opioids +/- adjuvants
- opioids for mild-mod pain +/- non-opioids +/- adjuvants
- opioids for mod-sev pain +/- non-opioids +/- adjuvants
principles of pain control
● Add 50-100% of PRN doses to around the clock scheduled doses
● Rescue PRN doses = 10-20% of daily opioids requirements
what kind of dosing regimen is preferred for chronic pain
Scheduled doses > PRN for chronic pain
What types of pain are the CDC guidelines not applicable for?
CDC Clinical Practice Guidelines for Prescribing Opioids for Pain – US 2022: Guidelines are NOT applicable to management of sickle cell disease, cancer-related pain or palliative care
what drugs are opioids CI with
BZD & other CNS depressant
what type of opioids should be initiated first
use Immediate-release first
types of opioid problems
Tolerance: ↓ response to normal dose → higher dose to experience the same effect of opioids
Dependence: cannot function normally without opioids → withdrawal
Addiction: compulsive drug use despite negative consequences.
how is morphine cleared
Active morphine-6-glucuronide is renally eliminated
characteristics of fentanyl
Opioids tolerance: someone who can tolerate 60 mg of morphine per day → only can be used in opioids tolerant patients (black box)
Absorption can be erratic (i.e. heat can ↑ absorption, fever) Onset slow & reach steady state slower = Q72h
characteristics of ketamine
Reverses opioid tolerances –> must reduce baseline opioid drastically when initiating (eg >50%)
Difficult to use, too many ADRs + questionable efficacy
adjuvants for pain control
● GABA acting anticonvulsants (e.g. Gabapentin, Pregabalin)
○ Beware of drowsiness
● SNRIs (Duloxetine), Tramadol (both SSRI + Opioids)
○ Double action due to serotonergic effect and opioid agonist
● Lidocaine patches (analgesics)
how to convert morphine to fentanyl patch
2-3.6mg morphine = 1mcg/h fentanyl patch
how to convert morphine to oxycodone
30mg of morphine = 20mg of oxycodone
how to convert morphine to methadone
<60mg morphine: 2-7.5mg/day of methadone
60-100mg morphine (and pt<65yo): divide by 10
200mg and more morphine (and/or pt>65yo): divide by 20 (max methadone: 45mg/day)
how to convert morphine to codeine
x (20/3)
how to convert morphine to tramdol
x10
how to treat dyspnea (3)
- morphine PRN, titrated to respiratory rate
- furosemide PRN for fluid overload
- BZD (lorazepam 0.5-2mg Q3-6h PRN) for anxiety in dying pts
how to treat secretion (4)
● IV/SC Glycopyrrolate (not in SG)
● Scopolamine 1.5 mg patches q72h
● Atropine 1% ophthalmic solution 1-2 drops q2-4h PRN
● Hyoscyamine 0.125-0.25 mg q4h (max 1.5 mg/day)
how to treat agitation/delirium (4)
● Antipsychotics as last resort (questionable efficacy & undesirable SE)
○ SC/IV Lorazepam 0.5-2 mg q4h PRN (max 30 mg/day)
○ SC/IV Haloperidol 0.5-2 mg q1-4h PRN
○ PO/SL Olanzapine 2.5-7.5 mg q2-4h PRN (max 30 mg/day)
○ PO/PR/IV Chlorpromazine 25-100 mg q4h PRN
how to treat insomnia (6)
- sleep onset insomnia –> melatonin 1-5mg QHS, lemborexant 10-20mg QHS
- restless leg syndrome
- intermittent: carbidopa/levodopa 25/100mg QHS PRN
- chronic: ropinorole 0.25mg 1-3h before bedtime, pregabalin 50-350mg 1-3h before bedtime, gabapentin 100-2400mg in divided doses 2h before bedtime
how to treat anorexia (3)
○ PO Metoclopramide 5-10 mg QDS 30 min before meals
○ PO Olanzapine 2.5-5 mg
○ IV/PO Dexamethasone 3-8 mg/day
how does early palliative care benefit pts (4)
improved QoL, mood, depression scores, lower proportion had aggressive end of life care
IV morphine dose to PO
X 3
