to be decided

Question 1

Symptoms and signs suggestive of opioid toxicity

Answer 1

There is a spectrum from mild to severe toxicity that includes persistent nausea or vomiting, persistent drowsiness, confusion, visual hallucinations, myoclonic jerks and respiratory depression.

Pinpoint pupils are not a useful sign of opioid toxicity in a patient on long term opioids.

Question 2

Oral morphine is available in two forms:

Answer 2

• Normal / immediate release tablets and liquid – would be expected to be effective after 20-30 minutes and to last up to 4 hours, e.g. oramorph liquid or sevredol tablets
• Modified /slow release tablets, granules, or capsules – would be expected to last up to 12 hours, e.g. Morphine Sulphate Tablets (MST), Zomorph capsules

Question 3

starting dose for oromorph

Answer 3

Starting doses.
If the patient has been on maximum strength co-codamol then MST 20mg bd is usually appropriate.

Question 4

• Which patients need a lower dose of morphine?

Answer 4

Elderly or frail patients may require lower starting doses.

Patients with renal failure will accumulate morphine metabolites and the dose and frequency should be reduced or a non-renally excreted alternative considered (e.g. fentanyl).

Question 5

• how do you increase doses of morphine (titrating dose)

Answer 5

Titrate dose upwards by 30-50% increments to relieve pain or until unacceptable adverse effects occur. Always check the pain is opioid sensitive.

Question 6

how do you calculate morphine PRN dose?

Answer 6

All patients on modified release morphine should have normal release morphine available p.r.n. for breakthrough pain, i.e. 1/6th of their total 24 hour morphine dose, e.g. a patient on MST 20 mg bd should have oramorph 5-10mg p.r.n.

Question 7

diamorphine and morphine sulphate for injection can be given how? what is their duration action?

Answer 7

Both diamorphine and morphine sulphate for injection can be given subcutaneously (SC), either as required (with a duration of action of up to 4 hours) or as a continuous SC infusion via a syringe driver.

Question 8

Parenteral diamorphine potency compared to oral morphine

Answer 8

Parenteral diamorphine is 3 times more potent than oral morphine

Question 9

Parenteral morphine sulphate potency compared to oral morphine

Answer 9

Parenteral morphine sulphate is 2 times more potent than oral morphine.

Question 10

the total 24 hour SC infusion diamorphine dose conversion from total 24 hour hour oral morphine dose

Answer 10

The total 24 hour subcutaneous continuous infusion diamorphine dose should be one third of the total 24 hour oral morphine dose e.g. a patient on 30 mg oral morphine bd. would require approximately 20 mg diamorphine SC over 24-hours (60 mg in 24-hours divided by 3) or 30 mg morphine sulphate SC over 24-hours (60 mg divided by 2).

Question 11

Fentanyl transdermal patches have a duration of action of ?They are mainly suitable for which patients?

Answer 11

Fentanyl transdermal patches have a duration of action of 72 hours.
They are mainly suitable for patients with severe chronic pain already stabilised on other opioids.
Transdermal buprenorphine patches are also available.

Question 12

alternatives for patients who have not tolerated morphine

Answer 12

Oxycodone has similar pharmacological properties to morphine and is a useful second line strong (step 3) opioid for patients who have not tolerated morphine.
It is available as an immediate release (oxynorm) and slow release preparation (oxycontin).

Other strong opioids available include alfentanil, methadone and different preparations of fentanyl (sublingual, buccal and nasal).

Question 13

summary of non-pharmacological treatments for pain in palliative care

Answer 13

• Palliative radiotherapy e.g. for bone pain
• Palliative chemotherapy e.g. for tumour masses compressing viscera or nerves
• Surgery e.g. intramedullary nail for pain from a femoral metastasis
• Anaesthetic and neurosurgical interventions e.g. paravertebral nerve block
• Psychological interventions e.g. cognitive behavioral therapy
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Complementary therapies e.g. aromatherapy

Question 14

Definition of advanced care planning

Answer 14

a voluntary process of discussion and review to help an individual who has capacity to anticipate how their condition may affect them in the future and, if they wish, set on record choices about their care and treatment

Question 15

Formalized outcomes of advance care planning (Mental Capacity Act 2005) may include one or more of:

Answer 15

• Advance statement of wishes to inform subsequent best interest judgments
• Advance decisions to refuse treatment which are legally binding if valid and applicable
• Appointment of Lasting Powers of Attorney for ‘Health and Welfare’ and/or ‘Property and Affairs’.

Question 16

Pain in a patient with cancer may be caused by;

Answer 16

• the disease itself e.g. bone invasion
• the treatment e.g. radiotherapy induced oesophagitis
• a concurrent disease e.g. osteoarthitis

Question 17

Common pain syndromes in cancer

Answer 17

• bone pain
• visceral pain
• Headache due to raised intracranial pressure
• neuropathic pain
• infection:Is an important cause of pain that is often overlooked e.g. pleuritic chest pain of pneumonia or soft tissue pain of cellulitis.

Question 18

• Bone pain: features and treatment

Answer 18

Features: Either a dull ache over a large area or well localised tenderness over the bone. Often worse on weight bearing or with movement.

Treatment: NSAIDS (e.g. diclofenac 50mg tds), radiotherapy and bisphosphonates (e.g. pamidronate infusion).

Question 19

Visceral pain: features and treatment

Answer 19

Features:
* Dull, deep-seated, poorly localised pain.
* There may be tenderness over a particular organ (e.g. liver).
* Some visceral pain is spasmodic such as bladder spasm or bowel colic.

Treatment For constant dull visceral pains follow the analgesic ladder.
* Pain caused by visceral stretch such as liver capsule pain can be treated by NSAIDS or corticosteroids to reduce inflammation.
* Colic pain responds to anticholinergic drugs such as subcutaneous hyoscine butylbromide for bowel colic and oral oxybutynin for bladder spasm.

Question 20

Headache due to raised intracranial pressure: features and treatment

Answer 20

Features: dull, oppressive pain usually worse on waking, coughing, sneezing and may be associated with nausea and vomiting.

Treatment: Corticosteroids to reduce the oedema (e.g.16mg po dexamethasone daily, reduced to lowest effective dose), NSAIDs and paracetamol.

Question 21

Neuropathic pain: features and treatment

Answer 21

Features: Pain in an area of abnormal sensation. It may be localised to specific dermatomes or over a wider, less defined area. There may be altered sensation in the area such as numbness or hyperaesthesia and autonomic changes such as pallor or sweating. The patient may describe the pain as ‘pins and needles’ or burning.

Treatment:
* Antidepressants (amitriptyline 10-75 mg nocte)
* and anticonvulsants (gabapentin 100-1200mg tds, pregablin 25-300 mg bd ).
* Compression of a nerve may be helped by corticosteroids.

Question 22

explain the analgesic ladder

Answer 22

Question 23

Side effects of opioids and some of the treatments to counteract

Answer 23

Strong opioids are generally tolerated well when titrated properly. The following side effects may be predicted and treated:
* Constipation is almost universal. Always prescribe a laxative e.g. co-danthramer.
* Nausea and vomiting occur in about one third of patients starting strong opioids but usually settles within a few days. Prescribe a p.r.n. antiemetic (e.g. haloperidol) and consider a regular antiemetic if the patient is already nauseated or has had sickness in the past.
* Drowsiness may occur when starting or changing the dose of opioid. This usually improves within 48 hours. Excessive sedation may indicate excessive dosing or co-morbidity e.g. renal impairment.
* Confusion and visual hallucinations are rare if the correct dose is given. Check the dose and renal function and consider an alternative opioid if confusion persists.
* Respiratory depression is rare if the opioid is titrated correctly.
* Psychological dependence and addiction are common fears amongst patients but are rarely a problem in clinical practice.