Pain + Syringe Driver

Question 1

What dose should breakthrough pain be?

Answer 1

1/6 of daily dose in 24h

Question 2

Describe the 5 steps of titrating morphine from starting dose up to MR

Answer 2

1. Begin on starting dose 4 hourly with same dose available for breakthrough pain
2. Review requirements every 24h
3. Adjust dose as rqd (no more than 30-50% at each step)
4. Once good pain control is achieved, total 24h requirement converted to
5. Modified release
   MR is given BD with breakthrough medication available at 1/6th of 24h dose

Question 3

What is preferred to transdermal

Answer 3

Oral MR morphine

Question 4

What should be given to all patients on strong opioid

Answer 4

Laxative

Constipation is usually persistent

Question 5

What are other SE of opioids [8]

Answer 5

• respiratory depression (hypoxaemia and acidosis)
• constipation
• urinary retention (sphincter contraction and decreased peristalsis)
• N&V
• bradycardia or tachycardia, palpitations
• muscular rigidity
• confusion, mood changes
• toxicity

Question 6

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

Answer 6

Fentanyl transdermal patch

Question 7

When should you be cautious with prescribing opiotes [1] and what is preferred [3]

Answer 7

CKD patients - be cautious when prescribing opiates

Fentanyl
Buprenorphine
Alfentanil

Question 8

How do you treat metastatic bone pain? [4]

Answer 8

Strong opioid = most evidence
Biphosphonates
Denosumab
RT

Question 9

If increasing dose what should you increase by

Answer 9

30-50%

Question 10

What is an alternative to morpine and why ?

Answer 10

Oxycodone
Less sedation / vomting and itch
But causes more constipation

Question 11

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

Answer 11

Divide dose by 10

Question 12

What do you do if going from morphine to oxycodone

Answer 12

Divide by 2 as oxycodone 2x as strong

Question 13

What is the equivalent dose of morphine for 12 microgram fentanyl transdermal

Answer 13

30mg daily

Question 14

What is the equivalent dose of morphine for 10mg buprenorphine transdermal

Answer 14

24mg daily

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 [2]
Is metabolism of morphine affected by kidney failure?
Is metabolism of morphine affected by liver failure?

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 [6]

Answer 19

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

Question 20

What can aggravate opioid toxicity [1]

What opioids are preferred in CKD [3]

Answer 20

AKI

• Afentanil
• Brupernorphine
• Fentanyl

Question 21

What do you do if only mild morphine toxicity [7]

Answer 21

Explain to nurse
Look for renal impairment
Reduce dose
Hydration 
Check for malignant hypercalcaemia (reversible cause of delirium) 
Sepsis screen for derlerium 
Antagonist is NOT required

Question 22

How do you manage pain if opioid toxicity [4]

Answer 22

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

Question 23

When do you use a syringe driver [6]

Answer 23

Unable to take oral
Nausea
Dysphagia 
Obstruction
Weakness
Coma

Question 24

Most drugs are compatible with water but what drugs require 0.9% saline [4]

Answer 24

Ketamine
Octreotide
Odansetron
Ketorolac

Question 25

What is preferred opioid for pain

Answer 25

Diamorphine

Question 26

Contraindications to opioids [3]

Answer 26

Acute Respiratory Depression Risk of paralytic ileus Raised ICP

Question 27

WHO analgesic ladder

Answer 27

Assess, titrate and maintain Non-opioid = NSAID + PCM Weak opioids: DHC, codeine, tramadol Strong opioids: MORPHINE, DIAMORPHINE, etc

Question 28

``` Paracetamol MOA Indication [2] Caution [3] SE [2] Education ```

Answer 28

``` MOA: COX-1 blocker • Ind: mild to moderate pain, fever • Caution: alcohol dependency, hepatic impairment, dehydration • SE: toxicity and liver failure • Education: warn of overdose risk ```

Question 29

NSAIDS Eg [4] MOA [2] Indications [3]

Answer 29

E.g. IBUPROFEN, NAPROXEN, DICLOFENAC, ASPIRIN 1. Inhibitors COX-1 and COX-2 from converting arachidonic acid 2. to thromboxanes and prostaglandins Ind: mild to moderate pain (especially bone and soft tissue incl. bone mets), fever, inflammation

Question 30

NSAIDS | SE [9]

Answer 30

- GI upset and mucosal irritation causing peptic ulcer disease - renal damage - precipitate asthma - HTN - nausea, diarrhoea - headache, dizziness - drowsiness, insomnia - fluid retention - SJS

Question 31

What is the neuropathic co-analgesic pain ladder

Answer 31

* Steroid * Tricyclic anti-depressant * Anti-convulsant * NDMA antagonist * Neuroaxial therapies

Question 32

What are neuroaxial therapies [2]

Answer 32

- epidural, intra-thecal (diamorphine, levobuvicaine and clonidine) - coeliac plexus block, stellate ganglion block, sympathectomy)

Question 33

TCA Eg [2] MOA [3] Indications [[3]

Answer 33

E.g. AMITRYPTILINE, NORTRYPTILINE Block monoamine (serotonin and noradrenaline) reuptake by antagonising the amine transporter meaning more monoamine concentration at synapse Ind: - neuropathic pain syndrome - depression, migraine prophylaxis - abdominal pain unresponsive to traditional IBS regimens

Question 34

TCA SE [5] Interactions [3]

Answer 34

SE: - anti-cholinergic SEs, arrhythmia and heart block, sedation (or insomnia, agitation and confusion in elderly) - reduced seizure threshold - hyponatraemia due to SIADH ``` Interactions: Do not combine with: - other sedatives - drugs which cause QT prolongation (amiodarone, soltalol, antipsychotics) - MAOIs and SSRIs ```

Question 35

Anti-convulsants Eg [2] MOA [2] Indication [2]

Answer 35

Eg. GAPAPENTIN and PREGABALIN MOA: - Blocks T type calcium channels - inhibits other modulators and neurotransmitters Ind: - peripheral neuropathic pain, migraine prophylaxis

Question 36

Anti-convulsants | SE [4]

Answer 36

- N&V, diarrhoea, abdo pain and constipation - HTN, mood changes, depression - headache - ataxia

Question 37

NDMA receptor antagonist Eg MOA Indication [4]

Answer 37

Eg. Ketamine MOA: - prevents central sensitisation of dorsal horn neurones Ind: - neuropathic pain, complex ischaemic pain or phantom limb pain, anaesthesia

Question 38

NDMA receptor antagonist | SE [4]

Answer 38

hypertension, tachycardia, respiratory depression, hallucinations