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Kirsty 3.1 > CPT2: Pain > Flashcards

CPT2: Pain Flashcards

1
Q

What is pain

A

An unplesant feeling that is conveyed ti the brain by sensory neurons. The discomfort signals acute or potential injury to the body

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2
Q

What is pain?

A

Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort sugnals acute or potential injury to the body

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3
Q

Characterisitics of acute vs chronic pain

A

Referred pain: pain located at different site to pain site

Somatic pain: Pain receptors in tissues activated (aching, lnawing, sharp pain)

Visceral: Pain receptors in intestines, pelvis, chest or abdomen activated (aching, squeexing, pressure)

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4
Q

What types of pain is nociceptive?

A

Can be short lived (acute) or long lasting (chronic)

Somatic or Visceral

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5
Q

What is somatic and visceral pain?

What are these cause by?

What are the nature of these pains?

A

Nociceptive (acute/chronic):

  • Somatic (muscle, cutaneous or connective tissue) and visceral (internal organs) pain
    • Somatic - Pain receptors in tissue activiated
    • Visceral - (internal organs) Pain receptors in intestine, abdomen, chest, pelvis activated
  • caused by damage to body tissue
  • Somatic - a stabbing, aching, or throbbing (cramping and sharp too)
  • Visceral – squeezing, pressure, aching
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6
Q

What is neurological pain?

What is this caused by?

What is the nature of this pain?

Which patients is it commonly seen in?

A
  • Dysfunction of pain perception mechanisms -occurs when there is actual nerve damage
  • nerve tissue damage
  • burning, shooting or stabbing in nature
  • Common in post surgery, post herpetic neuralgia (shingles), diabetic ulcers, limb amputation or in cancer
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7
Q

What is mixed pain? What are examples?

A
  • Mixed pain has different pain components e.g. acute or chronic Nociceptive components and Neuropathic components
  • Examples
    • Failed back-surgery syndrome
      • Pain after failed back surgery
    • Complex regional pain syndrome
      • Damage to CNS and peripheral NS
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8
Q

What are goals of pain management?

A
  • To reduce pain
  • Improve physical functioning
  • Reduce pyschological distress
  • Improve quality of life
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9
Q

Key to effective management of pain

A
  • Understanding of different causes of pain
  • Assessment of pain
  • Management of pain
  • Reassessment and monitoring
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10
Q

What type of pain does this patient have?

32-year-old male wheelchair user, attended A&E having fallen out of his wheelchair and dislocated his shoulder. Currently has severe pain in shoulder area………….

A

Acute

Acute - lasts less than 6 months

Chronic - lasts longer than 6 months

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11
Q

What are question methods are there to assess pain in a patient?

A
  • PAIN
  • PQRST
  • SOCRATES
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12
Q

How would you assess pain using the PAIN format?

A

PAIN format:

Pattern: onset & duration

Area: location

Intensity: level

Nature: description

P-Q-R-S-T format

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13
Q

Describe how you would use PQRST to assess pain

A
  • Provocation – How the injury occurred & what activities increase/decrease the pain
  • Quality - characteristics of pain – aching (impingement), burning (nerve irritation), sharp (acute injury), radiating within dermatome (pressure on nerve)?
  • Referral/Radiation –
    • Referred – site distant to damaged tissue that does not follow the course of a peripheral nerve
    • Radiating – follows peripheral nerve; diffuse
  • Severity – How bad is it? Pain scale
  • Timing – When does it occur? p.m., a.m., before, during, after activity, all the time
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14
Q

What does impingement mean?

What does dermatone mean?

A

When a tendon (band of tissue) insider your shoulder catches on or rubs on nearby tissue or bone as you lift your arm - common cause of shoulder pain

A dermatome is an area of skin in which sensory nerves derive from a single spinal nerve root (see the following image). Dermatomes of the head, face, and neck

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15
Q

Describe how you would use SOCRATES

A

SOCRATES

S – SITE where is the pain?

O – ONSET when did it start? Sudden/gradual?

C – CHARACTER dull, sharp, throbbing, stabbing?

R – RADIATION

A – ASSOCIATED SYMPTOMS any other symptoms associated with pain?

T – TIME COURSE

E – EXACCERBATING/RELIEVING FACTORS

S – SEVERITY on scale of 0-10

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16
Q

What pain scales is there which can be used to assess pain?

A
  • Numeric or visual analog scales. e.g.
    • 0 — 10
    • None — Severe
    • Wung and Baker faces pain rating scale (Good for children)
    • Locate area of pain on picture
    • Flack scale (good for children)
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17
Q

What is the FLACC pain scale?

A
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18
Q

What is the univeral pain assessment scale?

A

Pain scale which includes combination of scale approaches e.g. Wong/baker face scale. numeric, verbal scale, activity tolerance

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19
Q

What are the treament interventions for pain?

A
  • Pharmaological interventios
    • Analgesics
    • Adjuvants
  • Non-pharmaological intervenetions

TREATMENT SHOULD ALWAYS FOLLOW WHO ANALGESIC LADDER

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20
Q

What is the WHO ladder?

When should medication be given?

A

https://professionals.wrha.mb.ca/old/professionals/files/PDTip_AnalgesicLadder.pdf

  • This is how pain should be controlled. It is not aleays necessary to start at setp 1 (e.g. if severe pain). It is not always necessary to step down (e.g. unless resolved).
  • Medication should be given around the clock rather than when required PRN.
  • Adjuvants can be added at any stage.
  • First route option oral. If this is not possible or tolerated consider intravenous. NEVER give IM

Step 1: Non-opiod +/- adjuvant

Step 2: Mild-opiod +/- adjuvant +/- non-opiod

Step 3: Strong-opiod +/- adjuvant +/- non-opiod

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21
Q

What drugs are used at step 1?

A

The main non-opioids drugs are:

  • Paracetamol
  • Aspirin
  • NSAIDs:
    • ibuprofen, diclofenac, naproxen, celecoxib, etorcoxib

With or without adjuvant

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22
Q

STEP 2 Drugs used are?

A

The main opioid drugs used at Step 2 are:

  • Codeine (mild – moderate) – pro drug of morphine
  • Dihydrocodeine (DHC) (moderate – severe)
  • Tramadol (moderate – severe) – MOA opioid and non opioid it inhibits noradrenaline reuptake and inhibits stimulation of serotonin release at synapses.
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23
Q

Drugs used at STEP 3?

A

The main opioid drugs used at Step 3 are:

  • Morphine
  • Diamorphine
  • Fentanyl
  • Buprenorphine
  • Oxycodone
  • Methadone
  • Pentazocine
  • Pethidine
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24
Q

What are adjuvants?

Examples?

A

Adjuvants are drugs with other indications that may be analgesic in specific circumstances:

Adjuvant drugs include:

  • •antidepressants (e.g. amitriptyline)
  • •anticonvulsants (e.g. gabapentin/ pregabalin)
  • •corticosteroids (e. g. dexamethasone)
  • •anxiolytics (e.g. diazepam)
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25
Q

Scenario:

A 45-year-old woman presents to her GP with a 2-day history of back pain following a lifting injury at work. The pain is constant and aching in character with radiation into the posterior aspect of both thighs as far as the knee. Physical examination shows her to be maintaining a very rigid posture with some spasm of the large muscles of the back. Her range of movement is very poor but there are no neurological signs in the legs.

  1. Which drugs may help this lady’s pain?
  2. What other advice should be given?

Options:

  • Regular paracetamol 1g QDS & bedrest?
  • Regular paracetamol 1g QDS + Ibuprofen 400mg TDS & remain active?
  • Co-codamol 8/500 2 tabs QDS & remain active?
A

Regular paracetamol 1g QDS & bedrest?

Regular paracetamol 1g QDS + Ibuprofen 400mg TDS & remain active?

Co-codamol 8/500 2 tabs QDS & remain active?

  • Bolded choice is most appropriate. It is important in patients with back pain to remain active as this will help recovery. (What guidelines?)
  • Codeine not as effective as NSAID for back pain but amay be used it NSAID intolerant or contraindicated
    • ibyprofen is safer NSAID - less side effects
  • Physiotherpay could also be considered if NSAID not working to avoid using more addictive pain medication
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26
Q

What is the mecanism of action of paracetamol?

What routes are available?

What needs to be considered before supplying this?

A

Mechanism of action:

  • Centrally acting (mediatd through activation of descending serotonergic pathways)
  • Antipyretic effect is thought to be due to central inhibition of a cyclooxygenase (COX) isoenzyme

Routes:

  • Oral(tab/cap/soluble/effervescent/dispersible/solution/suspension)
  • IV infusion (Restricted due to fatal accidnet)
  • Rectal

ORAL: If under 50kg reduce dose to 500mg (from 1g) 4 times a day

WEIGHT NEEDS TO BE TAKEN INTO CONSIDERATION

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27
Q

Effect of COX-1 and COX-2 on thrombotic events

A
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28
Q

What is the mechanism of action of non-selective NSAIDs?

What are examples?

What are routes of administration?

A
  • Mechanism of action - inhibit the activity of both COX-1 and COX-2 reducing inflammation, also inhibiting platelet aggregation
  • Ibuprofen. Diclofenac*, Naproxen, Piroxicam
  • Route – oral/IV/topical
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29
Q

What do you need to be careful with when supplying NSAIDs, especially diclofenac?

A

All NSAIDs have an increased risk of thromotic effects i.e. MI or stroke. This is especially seen with diclofenac and also when NSAIDs used at high doses for long periods.

NSAIDs should be used at lowest possible dose and short short time periods to reduce risk

Read MHRA advice on NSAIDs/ Diclofenac

https://www.gov.uk/drug-safety-update/diclofenac-new-contraindications-and-warnings

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30
Q

What advice should pharmacists give to patients buying diclofenac in pharmacies?

A

Diclofenac is available to buy in a pharmacy without a prescription at low doses (up to 75 mg/day) for short-term use (3 days). Pharmacists are asked to take the following steps when supplying diclofenac without prescription:

  • ask questions to exclude supply for use by people with established cardiovascular disease and people with significant risk factors for cardiovascular events
  • advise patients to take diclofenac only for 3 days before seeking medical advice
  • advise patients to take only one NSAID at a time
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31
Q

Which NSAIDs have lowest cardiovascular risks associated?

A

Naproxen and low-dose ibuprofen are considered to have the most favourable thrombotic cardiovascular safety profiles of all non-selective NSAID.

32
Q

Adverse effects of NSAIDs

A
  • Nephrotoxicity
  • Dizziness, headache, insomnia
  • Increased BP
  • Sodium and water retention
  • Bleeding problems

Important to check with pateints to see if suffering any adverse effects

33
Q

In which patients groups are NSAIDs cautioned?

A
  • Elderly
  • Allergic disorder
  • Pregnancy and breast feeding
  • Coagulation defects
  • Hepatic, cardiac, renal impairment
34
Q

What conditions is diclofenac contraindicated in?

What should happen if a patient has one of these conditions?

A

Diclofenac is now contraindicated in patients with established:

  • ischaemic heart disease
  • peripheral arterial disease
  • cerebrovascular disease
  • congestive heart failure (New York Heart Association [NYHA] classification II–IV)

Patients with these conditions should be switched to an alternative treatment at their next routine appointment.

Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (eg, hypertension, hyperlipidaemia, diabetes mellitus, smoking).

35
Q

In which groups are NSAIDs contraindicated?

A

Contraindications

  • Previous or active peptic ulceration
  • Hypersensitivity to aspirin
    • E.g. precipitated asthma attack in the past
36
Q

What drug interactions occur with NSAIDs?

A
  • Anticoagulants
    • Warfarin
    • DOACs (direct oral anti-coagulants e.g.rivaroxaban, apixaban)
    • Increase bleeding risk
  • Diuretics
    • Reduce effect of diuretics?
  • Lithium
    • NSAIDs increase lithium levels
37
Q

Mechanism of action of selective COX-2 NSAIDs?

Examples

A

Mechanism of action - inhibit the activity of COX-2 only

  • Celecoxib
  • Etoricoxib
38
Q

What effects can NSAIDs have on GI?

Patients most at risk?

When should these not be used and what should be given?

A
  • All NSAIDs associated with serious GI toxicity
  • Higher risk in elderly
  • Selective Cox-2 inhibitors associated with lower risk than non-selective
  • Avoid in those with active or history of GI ulcer/bleed
  • Use of PPIs should be used (in these patients?) e.g. lansoperazole or omperprazole
  • Scottish Patient Safety Programme – NSAIDs Safer Care Bundle
39
Q

What is nefopam mechanism?

Side effects?

Cautions?

A
  • Mechanism of action - thought to act centrally but is not an opioid
  • Adverse effects - nausea, vomiting, sweating, dry mouth, dizziness, light-headedness, blurred vision, headache
  • Cautions – glaucoma, urinary retention or renal impairment, hepatic impairment, elderly, pregnancy
40
Q

35 year old female is taking nefopam for chronic back pain. She is taking 30mg (1 tablet) three times daily and asks you if she can increase to 2 tablets three times daily as she is still in quite a bit of pain?

What would be your advice to this patient?

A

The maxium dose for nefopam is 90mg three times a daily, therefore increasing her dose would be a viable option. I would advice her to speak to her doctor about increasing the dose to see if there is potential reasons for not doing so. Also because the doctor would be responsible for the prescrptions for this.

I would advise her that she may experience increased side effects, though uncommon such as drowsiness, headache and insomnia

I would also ask her to try non pharmacological methods such as ibuprofen gel or heat rub as well as stretching and staying active. These may speed up recovery process

41
Q

How many and what opioid receptors are there?

A

4 opioid receptors – μ, κ, δ and ORL1

42
Q

What do these opioid receptors mediate?

μ, κ, δ and ORL1

A

μ – analgesia, respiratory depression, miosis, euphoria, constipation

κ – analgesia, miosis, respiratory depression

δ – analgesia

ORL1 – opioid receptor like-1, acts similarly to opioid receptors

43
Q

What receptor is morphine an agonist off??

Where and what is morphine metabolised to in the body?

How are these excreted?

A
  • Morphine – μ agonist
  • 90% metabolised in liver to morphine 3 glucuronide + morphine 6 glucuronide
  • Morphine 6 glucuronide is a very potent opioid. Its renal clearance is dependant on kidney function (long elimination half life in patients with reduced eGFR)
44
Q

What are patient fears/ beliefs regarding morphine

A
  • Addiction/dependence
  • Tolerance
  • Side effects
  • Implication that it implies final stages of life
45
Q

Common side effects or morphine

A
  • Dry mouth
  • Constipation
  • Nausea and vomitting
  • Resporatory depression
  • Drowsiness
46
Q

It is important to calculate equivalent doses when switching morphine containing preperations and routes. On this card and the other side contain doses

A
47
Q

What opiod agonist is fentanyl?

What routes are available?

Where is it metabolised and excreted?

Dose conversions

A
  • Semi synthetic opioid – μ receptor agonist
  • Metabolised in liver – inactive metabolites which are then excreted (safe in renal failure)
  • Transdermal analgesia (lipophilic) - patch
  • Morphine equivalence tables in BNF (prescribing in palliative care) e.g. 60mg morphine daily = Fentanyl ’25’ patch
  • Stable pain
  • Breakthrough analgesia
  • Slow IV, buccal and Intravenous infusion available
48
Q

What is oxyecodone an analogue off?

Routes?

Metabolism and elimiination

A
  • Synthetic analogue of morphine 2x as potent
  • Metabolised in liver to noroxycodone – oxymorphone
  • 20% excreted unchanged in urine. Renal impairment reduced clearance oxycodone + metabolites
  • Moderate – severe (palliative care)
  • Oral/parenteral
49
Q

Buprenorphine

A
  • Mixed agonist-antagonist activity at opioid receptors
  • Partial agonist at mu opioid receptors, also an antagonist at kappa-opioid receptors, an agonist at delta-opioid receptors, and a partial agonist at ORL-1
  • Moderate – severe
  • Sublingual, IM, oral, transdermal
50
Q

Pethidine

A
  • Agonist at the μ-opioid receptor
  • Moderate – severe acute pain
  • Short duration of action
  • Obstetrics
  • SC/IM/oral
51
Q

Methaone agonist off?

Cautioned in?

Routes?

A
  • A synthetic opioid
  • Primarily a mu-opioid agonist
  • Caution QT-interval prolongation
  • Severe pain or substance misuse
  • Long t1/2
  • Oral/SC/IM
52
Q

When can methadone be given twice daily

A

Severe pain (every 12hr MAX)

53
Q

Recap - what are adjuvant drugs are what are examples?

A

Drugs with other indications that may be analgesic in specific circumstances

Adjuvant drugs include:

  • antidepressants (e.g. amitriptyline)
  • anticonvulsants (e.g. gabapentin, pregabalin)
  • corticosteroids (e. g. dexamethasone)
  • anxiolytics (e.g. diazepam)
54
Q

What is the mechanism of action of NT and of Amitriptyline in particular

A

ADs inhibit the reuptake of NT at specific receptor sites therefore leadng to increased NT around the nerves in the brain.

Amitriptyline is a TCA - it works by inhibiting the reuptake of NA, Serotonin (5-HT) and DA.

Contraindications: arrhythmias, heart block, immediate recovery period after MI

S/E: Headache, arryhmias, dry mouth, hypotension, hallucinations, consipation, diarrohea, prolonged QT interval, headache

Renal excretion

55
Q

Mechanism of action of anticonvulsants

S/E?

A

Anxiety;depression; diarrhoea; dizziness; drowsiness; dry mouth; dysarthria; dyspnoea; headache;

Anticonvulsants suppress the excessive rapid firing of neurons during seizures. Anticonvulsants also prevent the spread of the seizure within the brain. Conventional antiepileptic drugs may block sodium channels or enhance γ-aminobutyric acid (GABA) function.

56
Q

Corticosteriods mechanism

A

These steroids act by binding to intracellular receptors which then act to modulate gene transcription in target tissues.

57
Q

What routes of analgesics are preferred? what other routes can be used?

A
  • Oral route whenever possible
  • Rectal, transdermal, topical and parenteral (IV,IM,SC) routes are sometimes used
  • Avoid injections, if possible
  • Epidural or intrathecal analgesic or anesthetic can be administered with injections or pump

◦Nerve Blocks

58
Q

What are general prescribing rules?

A
  • Regular doses of analgesia should be prescribed
  • Adequate doses of analgesia on an “as required” basis (PRN), in addition to the regular medication should be made available
  • Where possible give analgesia:
    • by mouth
    • by the clock
    • by the ladder (WHO)
  • Pain that does not respond to oral medication is unlikely to respond to analgesia given by a different route e.g. SC/IV unless there are absorption problems
  • Review the effectiveness of any medication on a regular basis
  • Ensure all patients on a step 2 or 3 analgesics are on regular laxatives and that the effectiveness of the laxative regime is being monitored
    • Stool softener and stimulant laxative should be used
59
Q

A patient comes into your community pharmacy looking for something for her headache, she also asks for something for indigestion?

  1. What painkillers are available OTC for headache?
  2. Which one would you recommend to this customer? Justify
A

First line treatments available are paracetamol o NSAIDs ibuprofen or aspirin. Seondl line treatment would be …

Due to the patients current GI problems (dyspepsia) then NSAIDs would not be reccomened in this case as they may worsen symptoms experienced by the patient. Instead paractamol up to 1g 4 times a day would be reccomeneded. (counseling advice e.g. no otc para)

If the headache persists or are frequently reoccuring, i would advice the patient to see their GP to potential diagnose the cause or receive prophylaxic treatement - it may be a headache caused by overuse of medication therefore this could be reviewed.

  • Consider Headache diary (NICE CG150) - minium 8 weeks
    • frequency, duration and severity of headaches
    • any associated symptoms
    • all prescribed and over the counter medications taken to relieve headaches
    • possible precipitants
    • relationship of headaches to menstruation.
  • Non-pharmacological advice headaches: plenty of fluid inake, hot compressions, plenty of rest

For the dyspepsia the patient could be treated with peptic for symptomatic relief e.g. Suitable antacids could include Rennie, Gaviscon and Maalox

Non-pharmacological advice indigestion: Avoid trigger foods and precipiating factors, stress reduction, do not eat more than 2hrs before bed.

however if any red flag signs (dysphagia, dysponea) are present a referral should be made to the GP.

60
Q

Guidline treatment options (read)

A

Chronic pain in palatative care/ cancer:

Oral route morphine. If not suitable Morphine SC or fenyac TD patches (specialist advice)

Sign 136: https://www.sign.ac.uk/assets/sign136.pdf

  • NSAIDs should be considered in the treatment of patients with chronic non-specific low back pain. B Cardiovascular and gastrointestinal risk needs to be taken into account when prescribing any non-steroidal anti-inflammatory drug.
  • Paracetamol (1,000-4,000 mg/day) should be considered alone or in combination with NSAIDs in the management of pain in patients with hip or knee osteoarthritis in addition to non-pharmacological treatments.
    • A combination of paracetamol 1,000 mg and ibuprofen 400 mg was significantly superior to regular paracetamol 1,000 mg alone for knee pain at 13 weeks but with an increased risk of gastrointestinal bleeding
  • Topical NSAIDs should be considered in the treatment of patients with chronic pain from musculoskeletal conditions, particularly in patients who cannot tolerate oral NSAIDs
  • Strong opioids should be considered as an option for pain relief for patients with chronic low back pain or osteoarthritis, and only continued if there is ongoing pain relief. Regular review is required.
    • Patients prescribed opioids should be advised of the likelihood of common side effects such as nausea and constipation.
    • All patients on strong opioids should be assessed regularly for changes in pain relief, side effects and quality of life, with consideration given to a gradual reduction to the lowest effective dose.
  • Gabapentin (titrated up to at least 1,200 mg daily) should be considered for the treatment of patients with neuropathic pain.
  • Pregabalin (titrated up to at least 300 mg daily) is recommended for the treatment of patients with neuropathic pain if other first and second line pharmacological treatments have failed. A Pregabalin (titrated up to at least 300 mg daily) is recommended for the treatment of patients with fibromyalgia.
  • Tricyclic antidepressants should not be used for the management of pain in patients with chronic low back pain. Amitriptyline (25 - 125 mg/day) should be considered for the treatment of patients with fibromyalgia and neuropathic pain (excluding HIV-related neuropathic pain).
    *
61
Q

Non-pharmological treatments

A
  • Non-pharmacological (Alternative pain interventions) – acupuncture, chiropractor, yoga, hypnosis, relaxation, massage
  • Manual therapy/exercise (physiotherapist)
  • Psychological/Psychosocial interventions
    • Promote spiritual health/refer for pastoral care
    • Maintain hope/prevent despair
62
Q

How and at what dose, formulation is morphine initated in a patient?

A
  • Initiating morphine – establish starting dose
    • Titration – based on previous meds, severity of pain and other factors (renal impairment, age, frailty)
  • If opioid naïve (not had opioid before) - 20-30mg daily (BNF 80)
  • Switching from regular weak opioid – 40-60mg daily (BNF 80)
  • Immediate release formulation should always initally be given e.g. sevredol or oramorph
  • If 1st dose no more effective than previous analgesic – increase dose by 30-50%
  • Then prescribe regular four hourly doses allowing extra doses of the same size whenever needed and reassessment after 24-48 hrs
  • When daily requirements known switch to sustained release formulation
  • Breakthrough analgesia should always be available in addition to regular analgesia
  • The dose for breakthrough analgesia should be one sixth to one tenth of the total 24hr dose of morphine
63
Q

This is an example of initaing morphine steps

A
  • If regular weak opioid not controlling pain, start immediate release morphine e.g. oramorph solution or sevredol tablets
  • Patient started taking oramorph solution 10mg, 4 hourly 2 days ago. The “as required” dose = 10mg
  • On review patient has taken two extra “as required” doses of 10mg oramorph in last 24 hours
  • Total oramorph solution in last 24 hours = 8 x 10mg = 80mg
  • Start MST dose = 80mg divided by 2 = 40mg 12 hourly. Stop regular oramorph solution
  • Make available the new dose of oramorph solution for breakthrough pain which will be 80mg divided by 6 = 10mg – 15mg “as required”
  • This is usually 4 hourly but in some situations may be needed more frequently up to hourly
64
Q

What is palliative care?

What does it involve?

Goals?

A

WHO definition:

  • The active total care of patients whose disease is not responsive to curative treatment
  • Control of pain, other symptoms, and of psychological, social and spiritual problems is paramount
  • The goal of palliative care is achievement of best quality of life for patients and their families
65
Q

Aim of palliative care

A

•Palliative care strives to help the person and his or her family to address issues, expectations, needs, hopes and fears; prepare for and manage self-determined life closure and the dying process; cope with loss and grief during illness and bereavement

66
Q

What is the management of cancer pain and other pallatative patients?

A
  • Analgesic drugs are the mainstay of managing cancer pain
  • Choice based on severity of pain, not stage of disease
  • Standard doses, regular intervals, stepwise fashion
  • Non-opioid…weak opioid…strong opioid…+-adjuvant at any level (WHO analgesic ladder)
67
Q

Mrs C had been taking co-codamol 30/500 two tablets four times daily.

What dose of diamorphine should be prescribed in the syringe driver?

A
68
Q

Mr A has been taking MST Continus® 60mg every 12 hours.

What dose of diamorphine (there are supply problems for morphine) should be prescribed for the syringe driver and what dose should be prescribed for breakthrough pain?

A
69
Q

What is a syringe driver?

How is this used?

A

A syringe driver of syringe pump is a small infusion pump used to gradually administer small amounts of fluid to a patient

https://youtu.be/gMaV1aZYQXc

70
Q

How long does a syringe driver take to reach full effect?

How many medicines should be given?

What do you need to check?

A
  • When first set up or after dose changes, it will take 4-8 hours for full effect to be achieved. If symptoms are acute a concurrent rescue dose should be given
  • Use the least number of medicines possible – check compatibility (drug AND diluent)
  • Is the drug suitable for subcutaneous infusion? ​
    • Scottish pallitative care guidlines contain section where compatabilitu of drugs and dilluents can be checked
71
Q

Where are syringe driver pumps commonly administered?

Irritancy can occur, how can this be avoided?

A
  • The subcutaneous tissues of the pectoral region and anterior abdominal wall
  • Irritancy

–cyclizine, methotrimeprazine

–allergy to nickel needles occasionally

–change site if painful or inflamed

–dilute mixture so less concentrated, bigger volume

–change of drug

–addition of hyaluronidase1500 units (increases permeability), hydrocortisone 50 - 100mg or dexamethasone 0.5 - 1mg to the syringe

–switch to teflon canula

–IM rather than SC

72
Q

While on analgesic medication what is important to do/ monitor?

A
  • Pain assessment tools
    • Is treatment effective
  • Analgesic use
    • How often using breakthrough medication
    • How often requesting analgesic med
  • Side effects
73
Q

What are counselling points for paracetamol?

A
  • Most effective when taken regularly
  • Do not take any other paracetamol containing products e.g. OTC products for example lemsip, co-codamol
  • Do not take more than 8 tablets in 24 hours
74
Q

What are counselling points for NSAIDs?

A
  • Take with or after food
  • Medicines Sick Day Rules
    • Stop taking medication if Vommiting or diarrohea (2 or more episodes or either) as can lead to dehydation and kidneys not working
    • Stop if Fever, sweats or shaking (unless minor)
    • Restart again once well (24-48hr after eating and drinking normally)
    • If in doubt contact health professional

Patient leaflet: https://ihub.scot/media/1401/20180424-web-medicine-sick-day-rules-patient-leaflet-web-v20.pdf

Professional leaflet: https://ihub.scot/media/1402/20180424-web-medicine-sick-day-rules-professionals-leaflet-web-v20.pdf

75
Q

Opioid counselling

A
  • Most opioids cause drowsiness therefore counsel patient about this in relation to daily activities
  • Nausea usually resolves within several days
    • If needed Antiemetic can be prescribed
76
Q

Mr B is a 71 year old man with lung cancer and raised intracranial pressure. His current drugs are:

MST Continus® tabs 30mg every 12 hours

Oramorph® Oral Solution 10mg when required for breakthrough pain

Dexamethasone tabs 4mg daily

Cyclizine 50mg tablets three times daily

Co-danthrusate (Only oral solution available in BNF78)

His condition is deteriorating, and a syringe driver is commenced. What recommendations would you make regarding the drugs for use in a syringe driver and the dose of the analgesic that would be required?

A

Dose for syringe driver: Oral Morphine (In MST) to subcutaneous diamorphine (Reccomended choice). 1/3 or oral morphine = subcutaneous diamorphine so 20mg/24hr

  • Oramorph Should still be used at the same dose as required for breakthrough pain
77
Q

GUIDELNES:

A
  • NICE Clinical Guideline 140 – Palliative care for adults: strong opioids for pain relief (2012 - Aug 2016 updated)
  • NICE CKS – Palliative cancer care (pain)
  • SIGN 136 - Management of chronic pain (Dec 2013)
  • The British Pain Society (BPS) - Opioids for persistent pain: Good practice
  • NICE Clinical Guideline 177 - Osteoarthritis: care and management
  • SIGN 155 - Pharmacological management of migraines (Feb 2018)
  • NICE Clinical Guideline 150 - Headaches in over 12s: diagnosis and management
  • NICE Clinical Guideline 173 – Neuropathic pain – pharmacological management Nov 2013 (updated Sep 2020)
  • NICE CKS – Analgesia – mild to moderate pain
  • Scottish Palliative Care Guidelines
    • www.palliativecareguidelines.scot.nhs.uk
  • NICE CKS – NSAID – prescribing issues

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