Pain/Palliative Care

Question 1

What principles do WHO follow in pain prescription?

Answer 1

• Oral admin when possible
• Analgesia at regular intervals
• Prescribe according to pain intensity
• Adapt dosing to the individual
• Patient centred decision making

Question 2

What is step 1 of the WHO ladder?

Answer 2

Non-opioids - paracetamol, NSAIDS

Question 3

What is step 2 of the WHO ladder?

Answer 3

Weak opioids - dihydrocodeine, codeine, tramadol

Question 4

What is step 3 of the WHO ladder?

Answer 4

Strong opioids - Hydromoprhine, morphine, fentanyl, oxycodone, diamorphine

Question 5

What is step 4 of the WHO ladder?

Answer 5

Other - nerve block, epidural, PCA pump, spinal stimulation

Question 6

What adjuvants can be used in the WHO ladder for:

a) raised ICP?
b) neuropathic pain?
c) cramp?
d) bone pain?
e) bowel spasm?

Answer 6

a) corticosteroids
b) pregablin, gabapentin, antidepressants, anticonvulsants
c) muscle relaxants
d) bisphosphonates
e) antispasmodics (hyoscine butylbromide)

Question 7

How does paracetamol work?

Answer 7

Unknown, possibly COX2 inhibition

Question 8

What are the indications, contraindications and side effects of paracetamol?

Answer 8

I: First line pain management
CI: None
SE: None

Question 9

What is the standard dose of paracetamol?

Answer 9

1g QDS, max 4g

Question 10

How do NSAIDS work?

Answer 10

Selective inhibition of COX 1 or COX2 and therefore prostaglandin syntehsis

Question 11

What is the function of COX1?

Answer 11

Carries out routine physiological functions

Question 12

What is the function of COX2?

Answer 12

Induced by pain and inflammation

Question 13

Why do we not just use COX2 inhibitors then?

Answer 13

Although the are more specific, they have cardiovascular side effects

Question 14

What are the indications, contraindications and side effects of NSAIDS?

Answer 14

I: inflammatory pain
CI: GI symptoms, renal failure, coagulation disorders, caution with HF
SE: gastric ulcer, bleeding, headaches, HTN

Question 15

How does codeine phosphate work?

Answer 15

Metabolised to morphine by CYP2D6

Question 16

What are the indications, contraindications and side effects of codeine?

Answer 16

I: Mild-moderate pain 1st line
CI: Raised ICP, bronchial asthma, severe respiratorry depression
SE: Constipation, nausea

Question 17

What is the dose of codeine?

Answer 17

20-60mg QDS (PO/PR/IM) - not IV as could cause anaphylaxis

Question 18

How does tramadol work?

Answer 18

Synthetic opioids with multiple active metabolites

Question 19

What are the indications, contraindications and side effects of tramadol?

Answer 19

I: Chronic pain, after bowel surgery
CI: Renal/liver failure, raised ICP, severe resp depression, elderly
SE: (opiate SEs) N&V, drowsiness, resp depression, pruritus, hallucinations, urinary retention, pinpoint pupils, risk of serotonin syndrome

Question 20

What is serotonin syndrome?

Answer 20

High body temp, agitation, hyperreflexia, tremor, sweating and dilated pupils.

This occurs when two or more serotonergic drugs are given at the same time

Question 21

What is the dose of tramadol?

Answer 21

50-100mg QDS (PO/IV)

Question 22

What are the indications for dihydrocodeine?

Answer 22

Moderate-severe pain, coughing, SOB

Question 23

What is the effect of erythromycin on opiods?

Answer 23

Increases effect (enzyme inhibitor)

Question 24

What is the effect of rifampicin and anticonvulsants on opioids?

Answer 24

Decreases effect (enzyme inducer)

Question 25

What are the indications for morphine?

Answer 25

Severe acute pain and chronic pain

Question 26

How does morphine work?

Answer 26

Acts on mu opioid receptors in the CNS

Question 27

What are the side effects of opiates?

Answer 27

``` Respiratory dperession Sedation Euphoria Pupil constriction Nausea and vomiting Constipation Pruritus Hypotension Bronchospasm Urinary retention ```

Question 28

What are the signs of opiate toxicity?

Answer 28

``` Myoclonic jerks Pinpoint pupils Hallucinations Decreased RR Confusion ``` (ensure this isn't bowel obstruction/hypercalcermia)

Question 29

How is opiate toxicity managed?

Answer 29

``` Reduce opiate dose by 30-50% and check renal function Switch to different opioids If severe (RR<8, o2<90) give NALOXONE ```

Question 30

How do you prescribe an opiate

Answer 30

1. Start at 20-30mg daily if no previous opiod or 40-60mg if previous opiod 2. Titrate up and review regularly (caution in elderly/frail/renal) 3. Dose immediate release every 4hr (oramorph) OR modified release every 12hr (zomorph) 4. Always prescribe PRN alongside this for breakthrough pain 5. If immediate release, convert to modified release when safe 6. If pt keeps using PRN dose, review meds

Question 31

How much should a dose for breakthrough pain be?

Answer 31

1/6th - 1/10th of the TOTAL regular dose in 24h

Question 32

How do you switch from immediate release morphine to modified release?

Answer 32

Add up total morphine and divide by 2

Question 33

If modified release morphine isnt given adequate control, how do you give more?

Answer 33

Keep titrating the dose up but dont increase by over 50%

Question 34

Which pain med should never be used for dose titration or acute pain?

Answer 34

Fentanyl

Question 35

What is the 1st line drug for neuropathic pain?

Answer 35

Pregablin + amitriptylline

Question 36

What is the 2nd line drug for neuropathic pain?

Answer 36

Duloxetine (SNRI)

Question 37

What is 3rd line for neuropathic pain?

Answer 37

Gabapentin, ketamine or lidocaine patches

Question 38

What should be prescribed at EoL for pain and breathlessness for a patient with a) eGFR>30 b) eGFR<30

Answer 38

a) 2.5mg morphine SC every hour | b) 100micrograms alfentanil SC every hour

Question 39

What should be prescribe at EoL for nausea and vomiting for a patient with a) eGFR>30 b) eGFR<30

Answer 39

a) 50mg cyclizine SC every 8 hours | b) 1mg haloperidol SC every 4 hours

Question 40

What should be prescribe at EoL for agitation for a patient with a) eGFR>30 b) eGFR<30

Answer 40

ALL - 2.5mg midazolam SC every hour

Question 41

What should be prescribed at EoL for excess secretions for a patient with a) eGFR>30 b) eGFR<30

Answer 41

a) 400micrograms hyoscine hydrobromide SC every hour | b) 20mg hyoscine butylbromide SC every hour

Question 42

How do you convert oral opiod dose to palliative SC continuous syringe driver dose?

Answer 42

1. Add up total oral dose in 24hr (PRN +regular) 2. Divide by 2 to calculate dose 3. Divide by 6 to calculate PRN 4. Start syringe driver 4hrs before next oral dose is due, then discontinue it