• 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%

• 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