Pain + Syringe Driver

Question 1

What should patients be offered when starting Rx if advanced disease

Answer 1

Oral morphine modified release (MR) or immediate release
+
Oral immediate release for breakthrough pain

Question 2

What dose should breakthrough pain be

Answer 2

1/6 of daily dose

Question 3

What is usual starting dose and when would you consider lower dose

Answer 3

20-30mg MR a day
15mg BD
Combined with 5mg oral morphine solution for breakthrough

Lower dose if elderly, low BMI, renal impairment

Question 4

What is preferred to transdermal

Answer 4

Oral MR morphine

Question 5

What should be given to all patients on strong opioid

Answer 5

Laxative

Constipation is usually persistent

Question 6

What are other SE

Answer 6

N+V
Drowsiness
Dry mouth
Usually transient

Question 7

What can you give if not transient

Answer 7

Anti-emetic for drowsy

Alter dose if drowsy

Question 8

What is 1st line if unable to swallow but not for syringe

Answer 8

Morphine / dimorphine SC

Fentanyl transdermal patch

Question 9

When should you be caution when prescribing opiotes and what is preferred

Answer 9

CKD
Avoid morpine / codeine and precaution with oxycodone in renal impairment

Preferred

• Fentanyl
• Buprenorphine
• Tramadol
• Alfentanil

Question 10

How do you treat metastatic bone pain

Answer 10

Strong opioid = most evidence
Biphosphonates
Denosumab
RT

Question 11

If increasing dose as not enough what should you increase by

Answer 11

30-50% every 24 hours

Question 12

What is an alternative to morpine and why

Answer 12

Dose reduction - 25%
Oxycodone
Less sedation / vomting and itch
Usually causes more constipation

Question 13

What do you do to dose if going from codeine / tramdaol to morphine

Answer 13

Divide dose by 10

Question 14

What do you do if going from oral morphine to oxycodone

Answer 14

Divide by 2 as oxycodone 2x as strong

Question 15

If going from oral morphine to SC morphine

Answer 15

Divide dose by 2

Question 16

If going from oral morphine to SC diamorphine

Answer 16

Divide dose by 3

Question 17

If going from oral oxycodone to SC diamorphine

Answer 17

Divide dose by 1.5

Question 18

How is morphine metabolised

Answer 18

Liver to active metabolites
Excreted by kidney
Accumulates in kidney failure
Largely unaffected by hepatic failure

Question 19

What does opioid toxicity lead too

Answer 19

Delerium
Altered consciousness / sedation 
Confusion 
Vivid dreams
Hallucination
Myoclonus
Pinpoint pupil + resp depression = late sign

Question 20

What can aggravate opioid toxicity

Answer 20

AKI

Question 21

What do you do if only mild morphine toxicity

Answer 21

Explain to nurse
Look for renal impairment
Reduce dose
Hydration
Check for malignant hypercalcaemia (reversible cause of delirium)
Consider intracranial bleed / renal failure
Sepsis screen for derlerium
Antagonist is NOT required for mild - only use if life threatening

Question 22

How do you manage pain if opioid toxicity

Answer 22

Senior advise
Reduce dose
Consider opioid switch
Add non-opioid analgesia

Question 23

When do you use a syringe driver

Answer 23

Unable to take oral
Nausea
Dysphagia 
Obstruction
Weakness
Coma

Question 24

What do different colours suggest

Answer 24

Blue = mm per hour
Green= mm per 24 hours

Question 25

Most drugs are compatible with water but what drugs require 0.9% saline

Answer 25

Ketamine Octreotide Odansetron Ketorolac

Question 26

What is preferred opioid for pain

Answer 26

Diamorphine

Question 27

If patient is controlled how do you convert to modified release

Answer 27

Add total PRN and divide into 2 12 hour MR

Question 28

What are drugs that are largely septic metabolise so useful in renal failure

Answer 28

Fentanyl Buprenorphine EXPERT advice needed

Question 29

What can you do for morphine resistant pain

Answer 29

``` Methadone Ketamine Adjuvants such as NSAID, steroid, muscle relacant Nerve block Nerve pain ```

Question 30

Know drug conversion

Answer 30

OK

Question 31

What is Step 1 WHO pain ladder palliative care

Answer 31

Non-opiod e.g. paracetamol WITH weak opioid PRN +- NSAID with PPI

Question 32

What is Step 2

Answer 32

Weak opioid e.g. regular codeine / tramdol WITH strong opioid PRN + PRN anti-emetic and laxative +_ NSAID with PPI

Question 33

What is step 3

Answer 33

Strong opioid e.g. regular morphine With PRN strong opioid (1/6 of 24 hour dose in 4 hourly interval ) + PRN anti-emetic and laxative

Question 34

What do you do when pain well controlled

Answer 34

Consider switching to sustained release morphine MST

Question 35

What is diamorphine preferred for

Answer 35

Injections as rapidly soluble

Question 36

What should you avoid in renal failure

Answer 36

Oramorph Parenteral morphine sulphae Dimorphine Oxycodone

Question 37

What is difference between oxycontin and oxynorm

Answer 37

``` Oxycontin = slow release 12 hour Oxynorm = immediate release ```

Question 38

If current pain controlled on oromorph 10mg every 4 hours how do you switch to sustained release

Answer 38

MST 30mg BD | + oromorph 10mg PRN

Question 39

Patient confortable meds but changing to syringe MST continuous 30mg BD PO Glycopyrrinium 200mg 6 hourly SC CYclizine 50mg TDS PO

Answer 39

Morphine sulphate 30mg + Glyco 800mg + Cyclicine 150mg in 24ml of water over 24 hours PRN morphine sulphate SC 5mg max 2 hourly for pain PRN glyco SC 200mg 4 hourly for secretion PRN midazolam SC 2.5mg for agitation PRN levomepromazine SC BD for nausea