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Flashcards in PAIN RELIEF Deck (48):
1

What are the steps of the WHO analgesic ladder?

Step 1 - Paracetamol +/- NSAIDs

Step 2 - Weak opioid such as codeine phosphate

Step 3 - strong opioid such as oramorph

2

How might you minimise the side effects of opioids?

Antiemetic PRN and laxatives regularly

3

How might you minimise the side effects of NSAIDs?

Gastric protection eg lansoprazole

4

How might you minimise the side effects of steroids?

Prescribe early in the day to reduce insomnia

Gastric protection eg lansoprazole

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7

What are the characteristic features of visceral pain?

Dull pain

Poorly localised

8

What is the best form of analgesia for visceral pain?

Usually opioid responsive

9

What are the characteristic features of bone pain?

Well localised

Worse on movement

Tender focally

10

What is the best form of analgesia for bone pain?

Partially opioid responsive

NSAIDs

Radiotherapy

Corticosteroids and IV pamidronate

Prophylactic fixation if risk of fracture

11

What are the characteristic features of neuropathic pain?

Burning

Stabbing

Shooting

May be associated with sensory / autonomic changes

12

What is the best form of analgesia for neuropathic pain?

Partially opioid responsive

Tricyclic antidepressants - amitriptyline 10-25mg OD titrated up to 100mg if tolerated

Anticonvulsants - gabapentin 300 mg OD titrated up to 300mg TDS if tolerated

13

What are the characteristic features of muscular pain?

Spasm

Tightness

Ache

14

What is the best form of analgesia for muscular pain?

NSAIDs

Muscle relaxant - diazepam 2-5mg BD-TDS or baclofen 5mg TDS

15

A patient presents to hospital in severe pain due to a pathological fracture of the femur which is subsequently found to be caused by metastatic breast cancer. Her pain is eventually controlled with 10mg of oramorph every 4 hours. How would you convert this to slow release oral morphine sulphate (MST Continus) so that she only had to take 2 tablets per day?

Calculate morphine dose over 24 hours:

10mg x 6 = 60 mg

Divide by 2:

60 mg / 2 = 30 mg

So she needs 30 mg MST Continus BD

16

A patient is on regular morphine sulphate for continuous analgesia. What should the dose of PRN breakthrough analgesia be?

1/6th of the total 24 hour dose of morphine sulphate

17

A patient is on 30 mg MST Continus (prolonged release morphine sulphate) BD. What should the dose of PRN breakthrough analgesia be?

This equates to 60 mg over 24 hours.

1/6th of 60 mg is 10 mg of oramorph

18

What is the conversion ratio between tramadol and oral morphine?

5:1

19

A patient's pain is being well controlled on tramadol 100mg QDS however, it is decided that she should be switched to slow release morphine to minimise the number of tablets she is taking. What is the equivalent dose of slow release oral morphine sulphate (MST Continus)?

This equates to 400mg of tramadol over 24 hours.

The conversion ratio between tramadol and oral morphine is 5:1

So the equivalent dose of oral morphine is 80mg over 24 hours

So she should be on 40mg MST Continus BD

20

What is the conversion ratio between codeine phosphate and oral morphine?

10:1

So 60mg of codeine (standard dose) is equivalent to 6mg of oral morphine

21

What is the conversion ratio between oral oxycodone and oral morphine?

1:2

22

A patient's pain was being controlled on 10mg of oral oxycodone QDS whilst abroad. However on returning home it is decided that this should be swapped to an equivalent dose of slow release oral morphine as oxycodone is significantly more expensive. What is the equivalent dose of MST Continus (slow release oral morphine)?

This equates to 40mg over 24 hours

The conversion ratio between oxycodone and oral morphine is 1:2

So the equivalent dose of oral morphine is 80mg over 24 hours

So they should be on 40mg MST Continus BD

23

What is the conversion ratio between IV or SC morphine sulphate and oral morphine?

1:2

24

What are the indications for using continuous subcutaneous infusion of morphine sulphate for pain control?

Difficulty swallowing or taking oral medications safely

Nausea and vomiting

Bowel obstruction

Too drowsy to swallow tablets or unconscious

Requires multiple SC injections

25

How often should the site of subcutaneous infusion of morphine sulphate be changed?

Every 3-4 days

26

What features would indicate that the site of subcutaneous infusion of morphine sulphate needed to be changed?

Red

Hot

Tender

Swollen

27

How many drugs may be put through a single continuous subcutaneous infusion, as long as there are no problems with interactions?

Up to 4

28

A patient's pain is being controlled on 80mg of slow release oral morphine sulphate (MST Continus) BD, however, she is experiencing a lot of nausea and vomiting. It is decided that she should be started on continuous subcutaneous infusion instead. What is the dose of subcutaneous morphine sulphate that should be delivered over 24 hours?

Total dose of oral morphine sulphate over 24 hours is 160mg

Conversion ratio is 1:2

So equivalent dose is 80mg over 24 hours

29

What is the conversion ratio between IV or SC diamorphine and oral morphine?

1:3

30

What is the conversion ratio between IV or SC oxycodone and oral morphine?

1:4

31

What is the conversion ratio between IV or SC alfentanil and oral morphine?

1:30

32

What are the advantages of using a fentanyl patch rather than oral morphine for pain control?

Less constipation

33

How long will a fentanyl patch take to reach peak concentration in the body?

24-72 hours, so patient should be regularly topped up with PRN breakthrough analgesia

34

A patient's pain is currently being well controlled with 30mg of oral slow release morphine sulphate (MST Continus) BD, however, she is experiencing a lot of constipation despite laxative use. It is therefore decided that she should be swapped to a fentanyl patch to control her pain. What dose of fentanyl patch (in mcg/hour) should she be started on?

36-70mg of oral morphine over 24 hours is equivalent to 12 micrograms/hour of fentanyl patch

35

A patient's pain is currently being well controlled with 30mg of oral slow release morphine sulphate (MST Continus) BD, however, she is experiencing a lot of constipation despite laxative use. It is therefore decided that she should be swapped to a 12 micrograms/hour fentanyl patch to control her pain. How should the transfer be done?

The final tablet of MST Continus should be given at the same time as the initial patch application.

36

A patient's pain is currently being well controlled with 40mg of oral slow release morphine sulphate (MST Continus) BD, however, she is experiencing a lot of constipation despite laxative use. It is therefore decided that she should be swapped to a fentanyl patch to control her pain. What dose of fentanyl patch (in mcg/hour) should she be started on?

75-90mg of oral morphine over 24 hours is equivalent to 25 micrograms/hour of fentanyl patch

37

A patient's pain is currently being well controlled with 60mg of oral slow release morphine sulphate (MST Continus) BD, however, she is experiencing a lot of constipation despite laxative use. It is therefore decided that she should be swapped to a fentanyl patch to control her pain. What dose of fentanyl patch (in mcg/hour) should she be started on?

90-134mg of oral morphine over 24 hours is equivalent to 37 micrograms/hour of fentanyl patch

38

How often should a fentanyl patch be changed?

Every 72 hours

39

A patient is currently on 30mg of slow release oral morphine sulphate (MST Continus) BD. However, her pain is not being particularly well controlled and she is having to have breakthrough analgesia of 10mg of Oramorph roughly every 4 hours. What dose should her MST Continus be titrated up to?

Over 24 hours she is having 60mg of MST Continus plus 60mg of Oramorph, so 120mg.

She should therefore be started on 60mg of MST Continus BD.

40

What are the signs of mild opioid toxicity?

Vomiting

Increased drowsiness

Pinpoint pupils

41

What are the signs of moderate opioid toxicity?

Confusion

Muscle twitching/myoclonus

Vivid dreams/hallucinations

Agitation

42

What are the signs of severe opioid toxicity?

Respiratory depression (RR less than 8-10)

Hypotension

Loss of consciousness

43

How do we manage mild opioid toxicity?

Decrease opioid dose by 1/3rd

Ensure well hydrated

44

How do we manage moderate opioid toxicity in a patient on immediate release Oramorph?

Omit next dose

Re-start at a lower dose - decrease by 1/3rd

45

How do manage moderate opioid toxicity in a patient on slow release MST Continus (morphine sulphate)?

Temporarily convert to 4-hourly immediate release preparation on a decreased dose (by 1/3rd) and re-titrate

46

How do we manage moderate opioid toxicity in a patient on subcutaneous infusion of morphine sulphate?

Stop for 4-6 hours and review

If improving restart at lower dose - decrease by 1/3rd

47

How do we manage moderate opioid toxicity in a patient on a transdermal patch of fentanyl?

Seek specialist advice from palliative care team

48

How do we manage severe opioid toxicity?

Stop opioid

Consider naloxone 400 micrograms to 2mg IV

Repeat every 2-3 mins until respiratory function improves

Beware that naloxone effect wears of quickly so will need close monitoring