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12.10.08 Teaching

Pain ladder
  • Non-opioids
    • Paracetamol
    • NSAIDs
  • 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
      • 1/6 the daily total
  • 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
    • But don't stop suddenly!
  • N+V
    • Yup, but only in 30%
  • Cognitive impairment / "out of it"
    • Only if the dose is too high
  • Mortality
    • Regular opioids do NOT decrease life expectancy
  • Constipation
    • Yes, in ~100%


Pain
  • Physical
    • Allodynia, hyperpathia, hyperaesthesia
    • A-delta + C fibres
  • Psychological
    • e.g. Running vs chemi
  • Social
    • Expectations
  • 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
    • Buscopan


Terminal agitation

  • More common if:
    • Biochemical derangement
    • Young
    • Pre-existing cognitive impairment
  • Treatment (pref. IV/IM)
    • Haloperidol
    • Midazolam

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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