Cancer related pain & Analgesia

Question 1

Describe bone pain and how is it treated?

Answer 1

Dull ache over large area
or well localised tenderness over the bone
Worse on weight baring/movement
Tx: NSAIDs (Diclofenac 50mg tds), RT, Bisphosphonates (Pamidronate infusion)

Question 2

Describe visceral pain and how is it treated?

Answer 2

Dull, deep seated, poorly localised
Maybe tenderness over particular organ (liver)
Some pain spasmodic (bladder spasm/bowel colic)
Tx: Analgesic ladder, pain from visceral stretch NSAIDs/corticosteroids, sc hyoscine Butylbromide

Question 3

What is visceral stretch pain?

Answer 3

Pain from stretching such as liver capsule pain

Tx to reduce inflammation

Question 4

Describe headache (from inc ICP) and how is it treated?

Answer 4

Dull oppressive pain
Worse on waking, coughing, sneezing
maybe N&V
Tx: Corticosteroids (16mg po Dex), NSAIDs, Paracetamol

Question 5

Describe neuropathic pain and how is it treated?

Answer 5

Pain in an area of abnormal sensation, pins & needles, burning
Maybe localised to dermatome or less defined
Altered sensation (numbness, hyperaesthesia)
Autonomic changes (pallor, sweating)
Tx: Amitryptylline (10-75mg nocte), anticonvulsants (gabapentin 100-1200mg tds, pregabalin 25-300mg bd), corticosteroids is nerve compression

Question 6

What are the SE of strong opioids?

Answer 6

Constipation
Nausea & vomiting: 3rd of people, PRN antiemetic
Drowsiness
Confusion & visual hallucinations: Check dose & renal function
Respiratory depression
Psychological dependence & addiction

Question 7

What should always be co-prescribed with a strong opioid?

Answer 7

Laxative

Question 8

What are the signs & symptoms of opioid toxicity?

Answer 8

Persistent nausea & vomiting
Persistent drowsiness
Confusion
Visual hallucinations
Myoclonic jerks
Respiratory depression
Pinpoint pupils

Question 9

How is oral morphine available in, how long does it last & how long does it take to be effective?

Answer 9

Normal/immediate release tablets & liquid (oramorph liquid) last up to 4hours, works after 20-30mins
Modified/slow release tablets, granules or capsules, lasts up to 12hours

Question 10

What is the starting dose of morphine if the patient has been on max strength Co-codamol?

Answer 10

MST 20mg BD

Question 11

What opioid can be given to renal impairment patients and why?

Answer 11

Fentanyl

Non-Renally excreted

Question 12

What is the titration range when increasing doses of morphine?

Answer 12

30-50%

Question 13

Apart from laxatives what should always be prescribed to patients on MST?

Answer 13

Normal release morphine PRN for breakthrough pain at 1/6th of their total 24hour dose

Question 14

How is diamorphine/Morphine sulphate administered?

Answer 14

SC continuous infusion via a syringe driver
PRN
Duration upto 4hours

Question 15

How much stronger is diamorphine than oral morphine?

Answer 15

x3

Question 16

How much stronger is morphine sulphate than oral morphine?

Answer 16

x2

Question 17

When is transdermal analgesia suitable?

Answer 17

Fentanyl/ Buprenorphine patches
Duration of action: 72hours
Severe chronic pain already stabilised on other opioids

Question 18

When is Oxycodone used?

Answer 18

Patients who do not tolerate Morphine
Immediate release
Slow release

Question 19

How is oral codeine converted to oral morphine?

Answer 19

÷ 10

Question 20

How is Tramadol converted to oral morphine?

Answer 20

÷ 10