Pain ladder- Non-opioids
- Weak opioids
- Codeine
- 30-60mg QDS
- NB there is only 8-10mg in OTC co-codamol
- Metabolised => Morphine
- Approx. 1/8 - 1/10 the strength of morphine
- Side effects: Constipation, N+V, Drowsiness/confusion
- Doesn't work on 10% of people (can't metabolise to morphine)
- Dihydrocodeine
- Tamadol is half-way to step 3
- Strong opioids
- Morphine
- Diamorphine
- Oxycodone
- Fentanyl
- Buprenorphine
- Hydromorphone
- Methadone
- (Pethidine)
Morphine dosing
- Starting dose
- 5mg a good choice
- 10mg if young, fit
- 2.5mg if old + frail
- Give every 4 hours
- Use oral verisons
- Oramorph (liquid)
- Sevredol (pills)
- Breakthrough dose (PRN)
- 1/6 total daily dose (i.e. same as each regular dose)
- Prescribe 1 hourly
- Max. 2 doses every 4 hrs
- Max. 6 doses every 24 hrs
- Recalculation
- Add regular + breakthrough doses for the last 24 hrs
- Make this the new daily regular total
- i.e. Prescribe 1/6 of this every 4 hrs for the future
- Conversion
- Switch to slow-release morphine sulphate tablets
- Divide total daily dose by 2 and give every 12 hrs as MST
- Back-calculate to prescribe the PRN breakthrough dose
- If NBM
- Switch to subcut
- Use continuous infusion
- Twice as strong as oral, so divide total daily dose by 2
Morphine fears
- Tolerance exists, but is linear and not exponential
- => Doesn't ever stop working
- Doesn't get you high if taken for pain
- => No psychological dependance
- Can safely ween off
- N+V
- Cognitive impairment / "out of it"
- Only if the dose is too high
- Mortality
- Regular opioids do NOT decrease life expectancy
- Constipation
Pain- Physical
- Allodynia, hyperpathia, hyperaesthesia
- A-delta + C fibres
- Psychological
- Social
- Spiritual
Respiratory secretions - Increase in last 24hrs
- Important to get on top of it quickly, as reversal is hard
- Use anti-cholinergics to fix
- Hyoscine butylbromide
- Glycopyrronium
Terminal agitation
- More common if:
- Biochemical derangement
- Young
- Pre-existing cognitive impairment
- Treatment (pref. IV/IM)
Brief pain inventory

4 Signs of Imminent Death
Notes
- Chlorpromazine
- Typical antipsychotic
- Dopamine antagonist
- Additional antiadrenergic, antiserotonergic, anticholinergic and antihistaminergic properties
- O + Q signs of impending death
- NSAID side-effects
- GI
- Bronchospasm
- Fluid accumulation
- Nephrotoxic
- Headache
- Give pain relief:
- By mouth
- By the clock
- i.e. NOT just in response to pain!
- By the ladder
- Interpretation of pain
- e.g. After a marathon VS after chemo
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